Grcc Family And Medical Leave (Fmla) Request Form - Grand Rapids Community College Page 4
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Family and Medical Leave (FMLA) Request Form
Grand Rapids Community College Family and Medical Leave (FMLA) Request Form
Name:
Date:
Employee ID Number:
Department:
Mailing Address:
Home Phone:
Supervisor’s Name:
Phone Number:
Employee Group:
Campus Police
Meet and Confer
ESP
CEBA
Faculty
Adjunct Faculty
Normal Work Hours Per Week:
Date of Hire:
Anticipated Begin Date of Leave:
Anticipated Return to Work Date:
Reason for Request:
Birth and/or care of a child of the employee
Placement of a child into the employee’s family be adoption or by a foster care arrangement
In order to care for the employee’s spouse, child or parent who has a serious health condition
Spouse
Child
Parent
A serious health condition which renders the employee unable to perform the functions of the
employees position
I acknowledge that I have received the policy/rules relative to the Family and Medical Leave Act
Employee Signature:
Date:
Leave has been:
Approved
Denied
Supervisor Signature:
Date:
Human Resources Signature:
Date:
Distribution: Employee
Supervisor
Human Resources
Payroll
143 Bostwick Avenue, NE
Grand Rapids, Michigan 49503-3295
ph: (616) 234-GRCC
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Grand Rapids Community College is an equal opportunity institution. GRCC is a tobacco free campus. GRCC285 1/11
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Parent category: Business