Famu Military Leave Of Absence Request Family And Medical Leave Act (Fmla)
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2Military Leave of Absence Request
Family and Medical Leave Act (FMLA)
EMPLOYEE INFORMATION
Employee’s Name:
Employee ID:
REVIEWER INFORMATION
Reviewer’s Name:
Date:
EMPLOYMENT TYPE
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USPS
Faculty
A&P
Executive Service
OPS
CONTRACTUAL PERIOD
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9 month
10 month
12 month
Varied (OPS employees)
EXPECTED DATES OF LEAVE
Begin Date:
End Date:
REASON FOR LEAVE REQUEST
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A qualifying exigency due to the fact that your ( ) spouse, ( ) child, or ( ) parent is on covered active
duty or call to covered active duty with the Armed Forces.
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To care for a covered service member or veteran with a serious injury or illness affecting your ( )
spouse, ( ) child, ( ) or ( ) next of kin.
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Military Leave for Active Duty (active duty orders are required)
FMLA GUIDELINES
I understand that if my spouse, parent, or child is deployed or has been notified of an impending
deployment to a foreign county, I may be entitle to take up to a total of 12 weeks of FMLA leave during
a single 12 month period.
I understand that if my spouse, parent, child or next of kin has a serious injury or illness, I may be entitle
to military caregiver leave and take up to a total of 26 weeks of unpaid FMLA leave during a single 12
month period.
Employee’s Signature:
Date:
APPROVALS
Supervisor’s Signature:
Date:
Dean’s/Director’s Signature:
Date:
President’s/Provost’s/Vice President’s Signature:
Date:
Page 1 of 2
HR_TL 04/2016
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