Family And Medical Leave Act (Fmla) Request For Time Off - Ut Health Science Center
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FAMILY AND MEDICAL LEAVE ACT (FMLA)
REQUEST FOR TIME OFF
(Please return completed form to Office of Human Resources)
SECTION 1: To be completed by employee
Badge ID Number_________________
Name:
Department:
Contact information (best way to reach you during this period)
Address:________________________________________
______________________________________________
Phone:_____________________ * Email______________________
*Primary contact for FMLA. Regular US mail will be used if an email address is
not provided.
Reason for leave request:
Birth of a child and care after birth during the child’s first year of life
Placement with the employee of a child for adoption or foster care
Adoption/Placement: Documentation is enclosed is not enclosed
Serious non-work related or work related health condition
Serious health condition of a spouse, child, or parent
Military caregiver leave Documentation is enclosed is not enclosed
Military exigency leave Documentation is enclosed is not enclosed
Anticipated start date:
Expected date of return:
I am requesting full time off for the time period indicated above.
I am requesting a reduced schedule or intermittent time off for the time
period indicated above.
Medical Certification:
Does not apply
Is enclosed
Is not enclosed (Must be
submitted no later than 15 days from the date received.)
I understand that I may be required to provide a fitness for duty certification completed
by my physician and supervisor before I allowed to return to work.
Employee’s Signature
Date
SECTION 2: To be completed by supervisor
Supervisor’s Name:
Timekeeper’s Name:
SECTION 3: To be completed by Departmental Timekeeper
Please provide the employee’s leave balances (in hours): As of ____________
Month / Year
______Sick ______Vacation_____Personal
R-5/11
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