Lawson State Community College Family And Medical Leave Request (Family And Medical Leave Act Of 1993) Page 2
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2Lawson State Community College
Family and Medical Leave Request
Date: ______________________
(Family and Medical Leave Act of 1993)
This request must be submitted to your supervisor at least 30 days, when practicable, before the leave is to start.
Subject: Request for Family/Medical Leave
Employee’s Name:
____
Title:
Social Security #:
____
Supervisor:
Hire Date:
____
Length of Service:
Employee Status: Full Time: _______ Part Time: ________
I am requesting leave for the following reason(s):
□
The birth and care of my child
Expected delivery date:
Start date of leave: _______
Expected date of return: ____
□
The adoption of foster care placement of a child
(certified legal documentation must be provided)
Start date leave:
Expected date of return:
□
A serious health condition that makes me unable to perform the essential functions of my job
(Documentation from a healthcare provider must be provided)
Start date of leave:
Expected date of return:
□
A serious health condition affecting □ my spouse or my child, or parent, for which I am needed to
provide care
(medical documentation must be provided)
Start date of leave:
Expected date of return:
□
□
A serious illness or injury sustained in the line of duty on active duty affecting your
Spouse
□
□
Child
Parent for which you are needed to provide care for the service member.
□
□
□
A
Spouse,
child or
parent is on active duty or has been notified of an impending call to active
status
Employee has previously taken family medical leave
□
□
yes
no
If yes, total time taken:
Employee plans to take paid leave in addition to unpaid leave □ yes □ no
If yes, what type of leave?
□ Sick Leave □ Annual Leave □ Personal Leave #Hours __________
I certify that the leave/absence requested above is for the purpose(s) indicated. I understand that I
must comply with my employment agency’s procedures for requesting leave/approved absence
(and provide additional documentation, including medical certification, if required) and that
falsification of information on this form may be grounds for disciplinary action, including removal. I
have been employed with this company for at least 12 months and have worked at least 1,250
hours. My health benefits must be maintained during any period of unpaid leave under the same
conditions as if I continued to work, and I must be reinstated to the same position or an equivalent
job with the same pay benefits and terms of conditions of employment upon my return form leave.
If I do not return to work following FMLA leave for a reason other then the continuation, recurrence
or onset of a serious health condition which would entitle me to FMLA leave, or other circumstances
beyond my control, I may be required to reimburse the company for their share of health insurance
premiums paid on my behalf during my FMLA. I may elect to substitute accrued paid leave for
unpaid FMLA Leave.
Employee Signature
Date
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