Fillable Family Medical Leave Of Absence Request Form printable pdf download

Family Medical Leave Of Absence Request Form

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FAMILY MEDICAL LEAVE OF ABSENCE REQUEST FORM

The Family and Medical Leave Act (FMLA) entitles eligible employees the right to take up to 12 work weeks of unpaid, job-protected leave in a

rolling 12-month period for specified family and medical reasons. This Request must be completed by the employee to notify UAB of the need for

FMLA leave. In the event that the leave is spontaneous the Supervisor must submit the leave of absence request as soon as possible.

Full Name: ____________________________________________Employee#:_______________ Department: _______________________

Home Address: ___________________________________________________________________________________________________

Office Phone: __________________________ Home Phone: ______________________________Email:___________________________

OTAL

WORK WEEKS

Requested Leave Start Date: _____ / _____ / _____

Requested Leave End Date: _____ / _____ / _____

Please check one: ________ Continuous / Blocked Leave

________ Intermittent Leave

Check the type of leave and provide documentation as indicated

____

Employee’s Illness (Certification of Health Care Provider required)

____

Family Member’s Illness – Please check one below: (Certification of Health Care Provider for Family Member required)

Children 19 years or older are not included unless they are incapable of self-care due to mental or physical disabilities.

____ Child, Age ____

____ Spouse

____ Parent (not in-laws)

____ Sponsored Dependent (Affidavit must be on file in HR Benefits Office)

____

Birth of a child and care for newborn child (Certification of Health Care Provider, a copy of the birth certificate or confirmation from

Hospital of delivery required)

____

Adoption (Letter of Placement/ Adoption papers required)

____

Placement of Child for foster care (Letter of Placement required)

____

Paid Parental Leave (PPL) – Please check one below:

Paid Parental Leave runs concurrently with FMLA leave and will reduce the amount of FMLA leave available to an eligible employee.

____

Birth of a Child (Certification of Health Care Provider, copy of the birth certificate or confirmation from Hospital of delivery required)

____

Adoption (Letter of Placement/Adoption papers required)

Please check expected Paid Parental Leave type and dates:

*Supervisor/Manager/Department Head’s approval and signature is required for Intermittent and Reduced Schedule:

____

PPL Continuous:

My leave is expected to begin on _______________________ and end on_______________________

Family Medical Leave Of Absence Request Form

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