Durham Tech Family And Medical (Fmla) Leave Hours Form
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1Family and Medical (FMLA) Leave Hours Form
Employee Name: ___________________________________________________________
Employee ID #: _____________________________________________________________
Leave Begin Date: ______________________ Leave End Date: _____________________
If you are requesting intermittent leave time, please complete the number of hours used per month.
Number of Hours used: ________________________________
__________________
(Month and Year)
Date Received in Human Resources: _______________________
Date entered into Colleague: _________________________
Please return this form to Human Resources prior to going out on leave. Estimate the amount of time
you will be out and if you return prior to that date, please notify Human Resources so we can reduce
your time. You will still need to complete your regular leave forms and return them to your supervisor.
Revised Oct. 2014
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