Fillable Ucf-Human Resources - Medical Leave Request Form printable pdf download

MEDICAL LEAVE REQUEST FORM

Please Print, Type, or Write Legibly

Check one:

New Leave of Absence:

Revision of original request (superseding):

Extension of Leave:

Department Name: ____________________________________________ College/Division: _____________________________________________________

Employee ID #:_____________________ Position Title: ___________________________________ Check one: USPS:

A&P:

Faculty:

OPS:

Employee’s Name: ___________________________________________________________________________________________________________________

Last name

First name

Middle Initial

Home Mailing Address: ______________________________________________________________________________________________________________

Street Address/P.O. Box

City

State

Zip

Home Email Address: ______________________________________________ Campus Email Address: ____________________________________________

Campus Phone #: __________________________ Home Phone #: _____________________________ Cell Phone #:_________________________________

Type of Leave: Medical –Employee*:

Medical- Family *:

Employee’s own serious health condition:

Reason for Leave:

To care for the following family member with a serious health condition:

Child:

Spouse:

Parent:

Brother:

Sister:

Name of Relative: ___________________________ Relationship: _______________________

Injured Service Member:

Military Exigency:

Reason:_____________________________________________

* A UCF Certification of Health Care Provider Form for Self or a Family Member must be submitted with this request form.

Last Day of Work: ____________________________

Start Date: _____________________________ End Date: ______________________________

I anticipate returning to my normal work schedule and duties on: Date: _________________________ Time: __________________________________

My leave will be: A Full Unpaid Leave:

A Paid Leave:

A Combination of Paid and Unpaid Leave:

An Intermittent Leave:

A Reduced Work Schedule Leave (A proposed work schedule must be attached):

While not working I will use accrued:

Sick:

Annual:

Compensatory:

Leave Without Pay (LWO):

I am a sick leave pool member and I may be requesting sick leave pool hours: Yes:

No:

and accept a leave of absence as stated on this page. I further acknowledge that I have read the “Employee and Department Responsibilities for

I understand

Completion” page accompanying this form and I

understand

all of my leave responsibilities and the information provided therein:

Employee Signature: __________________________________________________ Date: ________________________________

For Use By Department and Human Resources

Department (Supervisor) must complete (Please type or print legibly):

Payroll Processor: _______________________________________________________email:_______________________________________________________

EPaf Processor:__________________________________________________________email:_______________________________________________________

HR Liaison:_____________________________________________________________email:_______________________________________________________

Approved

Yes:

No:

Signature Chair/Supervisor: ________________________________________________________ Date: ______________________________

Print Full Name: ______________________________________________________ Campus Extension:_____________________________

Email Address:____________________________________________________________________________________________________

Yes:

No:

Signature Dean/Director: __________________________________________________________ Date: _______________________________

Print Full Name: _____________________________________________________ Campus Extension: ______________________________

Email Address: _______________________________________________________________________________________________________

Comments:____________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

For HR Use Only

The Human Resources Director has Final Approval for all medical leaves of absence.

This request for leave of absence is approved:

YES:

NO:

Employee is on paid leave:

This leave counts toward the employee’s FMLA entitlement:

YES:

NO:

Employee is on unpaid leave:

During this leave the employee will use approximately _______________ weeks of their twelve (12) week FMLA entitlement and will have _________ weeks of

entitlement remaining for use in fiscal year ___________; Intermittent leave is not scheduled, it is not possible to provide the hours, days, or weeks that will

be counted against your FMLA leave entitlement. Your department will track your FMLA leave usage and you may request this information once in a 30-day

period.

Human Resources Director: By: _______________________________________________________ Date: _______________________________________________

Comments:_____________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Revised July 2015