Family Medical Leave Of Absence Request Form Page 2
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*PPL Intermittent:
My leave is expected to begin on _______________________ and end on_______________________
Please list the expected amount of leave (in hours) to be taken each day.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Expected Hours
Use the
Intermittent Utilization Form
to track intermittent leave time
SUPERVISOR/MANAGER/DEPARTMENT HEAD: Complete this section
Name (Print):
E-mail:
Date:
Signature:
Phone:
____
*PPL Reduced Schedule:
My leave is expected to begin on _______________________ and end on_______________________
Please list the expected amount of leave (in hours) to be taken each day.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Expected Hours
SUPERVISOR/MANAGER/DEPARTMENT HEAD: Complete this section
Name (Print):
E-mail:
Date:
Signature:
Phone:
I acknowledge that I have received a copy of the FMLA Notice. I understand that I must use my eligible accrued benefit time during my family
medical leave of absence. I understand that if I do not return to work after the leave, UAB may recover payments for health insurance made by
UAB during my leave of absence. I understand that failure to return to work on the date stated above as the leave end date or that
misrepresentation of facts on this form will jeopardize my reinstatement at UAB.
Employee Signature:
____________________________________________
Date: _____/_____/_____
SUPERVISOR/MANAGER/DEPARTMENT HEAD: Complete this section
Acknowledgement of Request:
Department Supervisor:
____________________________________________
Date: _____/_____/_____
Supervisor Phone Number: __________________________________________
FOR USE BY HUMAN RESOURCES
□
Sponsored Dependent (Adult or Child) affidavit verified by HR Records – Date: _____/_____/_____
Send this completed form to UAB HR Records, AB 254, via fax at 996-9954 and for Parental Leave email
ParentalLeave@uab.edu
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Parent category: Business