Family And Medical Leave Of Absence Application Form - Washington University In St. Louis
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2Family and Medical Leave of Absence Application Form
When the need for a leave of absence is foreseeable, you are required to request the leave 30 days in advance.
Examples of foreseeable events include planned medical treatment or your child's birth. For unforeseen events, such
as accidental injury causing a serious health condition, premature birth or sudden change in your health, you are
required to request the leave as soon as it is possible and practical to do so. The Medical School’s Family and
Medical Leave of Absence Policy contains an explanation of your rights and obligations regarding leaves of absence
under the Medical School’s Policy and the FMLA.
Name:
Employee ID #
Address:
Street / P.O. Box
City
Zip Code
Home Phone:
Today's Date:
Department:
Position:
Supervisor:
Date of Hire:
The reason you are requesting a leave of absence is (check the appropriate box):
EMPLOYEE MEDICAL LEAVE – your own serious health condition that prohibits you from performing the
essential function(s) of your job.
FAMILY MEDICAL LEAVE – the need to care for your spouse, child or parent who has a serious health
condition.
NEW CHILD LEAVE – the birth of your child or the placement of a child with you for adoption or for foster
care.
(If you gain a depdenent through birth or legal adoption of a child while you are on leave, you must
complete a benefits enrollment/change form within 62 days of this family status change in order to cover the
new dependent under your health care plan through the University. If this paperwork is not submitted to your
benefits office within 62 days of the birth/adoption, your child will not have coverage after the birth and will not
have any coverage if adopted. If you experience a family status change other than the addition of a dependent
while you are on leave, you must complete a benefits enrollment/change form within 31 days of the change.)
MILITARY EXIGENCY LEAVE – a qualifying exigency arising out of the fact that your spouse, child, or parent
is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in
support of a contingency operation.
MILITARY CAREGIVER LEAVE - the need to care for your spouse, child or parent or next of kin who has a
serious injury or illness incurred when he or she was serving as a member of the Armed Forces in the line of
active duty.
Have you taken a leave of absence under this Policy during the past twelve months?
Yes
No
If yes, when was the last such leave?
If your spouse works for the University, has your spouse taken a leave of absence under this Policy during the
past twelve months?
Yes
No
If yes, when was the last such leave?
Not applicable
If you are requesting NEW CHILD LEAVE, please answer the following questions:
Requested Leave Time: From ________________________
To __________________________
anticipated
actual date of birth or placement?
What is the:
or
If you are requesting a FAMILY MEDICAL LEAVE or EMPLOYEE MEDICAL LEAVE, please answer the following
questions:
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