Family And Medical Leave Of Absence Application Form - Washington University In St. Louis Page 2
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1
2 Yes
No
Have you submitted the necessary medical certification with this form?
Yes
No
Are you requesting full-time leave?
If you are requesting full-time leave, please answer the following questions:
What is your requested leave time? From _____________________ To ________________________
What other dates would be appropriate for the leave? ________________________________________
Yes
No
Are you requesting intermittent or reduced schedule leave?
If yes, please answer the following questions:
Why is it medically necessary for you to have intermittent or reduced schedule leave? ________________
____________________________________________________________________________________________
For which dates, times or schedules are you requesting leave? __________________________________
____________________________________________________________________________________________
For which dates, times, or schedules would be appropriate for your intermittent or reduced schedule leave?
____________________________________________________________________________________________
What employment positions are available that you believe would more easily accommodate your requested
leave? _____________________________________________________________________________________
___________________________________________________________________________________________
By signing below, you are certifying that you have read the Medical School’s Family and Medical Leave
of Absence Policy and that you agree to abide by the requirements of the Policy. Failure to abide by
these requirements may result in delay or denial of your leave, or it may result in disciplinary action up
to and including termination of your employment. By signing, you also affirm that you have been and
will be truthful and sincere in your request for a leave of absence.
Date:
Employee Signature:
This section to be completed by Department
Yes
No
Has this employee completed 12 months of service?
Has this employee worked more than 1250 hours in the past 12 months? Yes
No
Yes
No
Has this employee been on FMLA in the last 12 months?
Yes
No
Has this employee exhausted 12 weeks of FMLA leave?
□
Approved:
Enter approved leave online in the payroll system (HRMS).
Send a copy of the completed response letter, application and medical certification (if applicable) to Human
Resources, Campus Box 8002.
Disapproved (Explanation)*_______________________________________________________________
Date:
Supervisor Signature
*Contact the Human Resources Office.
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