Request For Family/medical Leave Of Absence Form printable pdf download

REQUEST FOR FAMILY/MEDICAL LEAVE OF ABSENCE

This form is to be completed by the EMPLOYEE requesting a paid or unpaid

leave of absence under provisions of the federal "Family and Medical Leave

Act of 1993" and City of St. Louis Administrative Regulation No. 133.

This

form should be completed and submitted to the Appointing Authority at least

thirty (30) days in advance of the beginning of such leave, except in those

cases where the nature of the medical/family emergency precludes such advance

notice.

EMPLOYEE NAME: _________________________________________________________

JOB TITLE: _____________________________________________________________

DEPARTMENT:

4. DIVISION/SECTION:____________________

REQUESTED LEAVE PERIOD:

From

To _____________________

PAID LEAVE REQUESTED:

_________________________________________________

I request Family/Medical Leave for the following reason:

For a personal serious health condition which renders me unable to

perform the functions of my job

For the anticipated birth and care of a newborn son/daughter

For the placement and/or care of a newly adopted child or foster

child

To care for the following qualifying relative with a serious health

condition (check one):

Legal spouse

Parent (includes natural or adoptive parent, stepparent, legal

guardian; does not include in-laws)

Person with "in loco parentis" status to the employee when the

employee was a child

Son or Daughter (includes natural, adoptive or foster child, or

stepchild, who is either under 18, or age 18 or older and

incapable of self-care because of a mental or physical

disability)

Child for whom employee has status as "in loco parentis"

If the requested leave is for the birth or adoption of a child, or the

placement of a foster child, does your spouse also work for the City of

St. Louis?

Yes

If the request for leave involves a "serious medical condition" of

either the employee or a qualifying relative, complete the following:

If the employee will be providing care for a qualifying relative,

please print the full name of the relative below:

Will the "serious medical condition" require hospitalization of

either the employee or the qualifying relative?

Yes

I certify that the information provided is correct to the best of my

knowledge.

Employee Signature

Date____________________

Request For Family/medical Leave Of Absence Form

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