Form Fmla-Hr1-Employee Request - Department Of Administrative Services Form 2009 Page 2
Download a blank fillable Form Fmla-Hr1-Employee Request - Department Of Administrative Services Form 2009 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fmla-Hr1-Employee Request - Department Of Administrative Services Form 2009 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4HR1 - Page 2
Duration of Leave:
_________________________________ (to) _______________________
(from)
(month/day/year)
(month/day/year)
Does your spouse work for the State?_______
(yes) or ______ (no)
? ______________________________________________________________.
If yes, which agency
_______ (yes) _____(no)
If yes, will he/she be taking leave for the same purpose?
Use of Accruals (check as applicable)
(1) Birth of Your Child
(a) Mother – Your absence for the “disability” portion of your pregnancy will automatically be charged to any accrued sick
leave. Once you have exhausted your sick leave, you may use personal leave, vacation accruals, comp time or unpaid leave.
Once you have completed the “disability” portion of your pregnancy (i.e., you have been certified as able to perform the
the requirements of your job by your attending physician), you may not use accrued sick leave. You may, however,
as above, use personal leave, vacation accruals, and/or comp time for the balance of your leave. This election must be
made before you begin your leave. If you do not elect to substitute personal leave, vacation accruals or comp time,
the leave will be unpaid.
(Answer “yes” or “no”) _____ I elect to use parental days to which I am entitled depending on my collective
bargaining contract.
(Answer “yes” or “no”) _____ I elect to use vacation, personal and/or comp time leave accruals.
If “yes”, fill in the amount of time you wish to use.
Parental Days:
_____________________________________________________________
Vacation Accruals:
_____________________________________________________________
Personal Leave:
_____________________________________________________________
Comp Time Leave Accruals: _____________________________________________________________
(b) Father –(check) ____Married ____Unmarried. You may elect to substitute 3 - 5 days of sick family leave and/or
parental days depending on your collective bargaining contract, personal leave ,vacation accruals and/or comp time for
unpaid leave.
(Answer “yes” or “no”) _____ I elect to use parental days to which I am entitled.
(Answer “yes” or “no”) _____ I elect to use sick family days to which I am entitled.
(Answer “yes” or “no”) _____ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use:
Parental Days:
_______________________________________________________________
Sick Family Days:
______________________________________________________________
Vacation Accruals:
______________________________________________________________
Personal Leave:
______________________________________________________________
Comp Time Leave Accruals: ______________________________________________________________
(2) Adoption (both State & Federal) or placement of a foster child with you (Federal FMLA only)
You may elect to substitute 3 - 5 days of sick leave (parental days) depending on your collective bargaining contract,
personal leave, vacation accruals and/or comp time for unpaid leave.
(Answer “yes” or “no”) ______ I elect to use parental days to which I am entitled.
(Answer “yes” or “no”) ______ I elect to use vacation, personal and/or comp time leave accruals.
If “yes,” fill in amount of time you wish to use.
Parental Days:
______________________________________________________________
Vacation Accruals:
______________________________________________________________
Personal Leave:
______________________________________________________________
Comp Time Leave Accruals: ______________________________________________________________
This form provided by the Department of Administrative Services
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cfn 552-0755 - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act) - Iowa Department Of Administrative Services
Business
Related Categories
Parent category: Business