Family And Medical Leave Request (Page 2 of 2) in pdf

Family And Medical Leave Request Page 2

USO Family & Medical Leave Request Form p.2

Dates of leave requested

I request leave from ____________________ to ____________________

I request intermittent leave according

to the following schedule:

I request a reduced schedule leave

according to the following schedule:

The total number of leave days I request is

Employee statement

I agree to return to work on _________________________________. If circumstances change such that I will not be able to

return to work on that date, I agree to inform my supervisor by submitting a NOTICE TO MY SUPERVISOR. I understand my

benefits will continue during my leave and I must arrange to pay my share of applicable premiums.

Signature _____________________________________________ Date ______________________

TO BE COMPLETED BY SUPERVISOR OR DEPARTMENT HEAD

Employee was hired on __________________

S/he started in this department on ______________________

Employee is

Part time

Full time

Current schedule commenced on _____________________ (If there was an earlier schedule, list below):

Employee has previously requested family or medical leave on _______________________

Leave taken from ______________ to ______________

Total time taken ____________

Name of supervisor or department head: _______________________________________

Date: ________________________ Telephone #: __________________________

All completed forms should be submitted to the HR Benefits Section and

will be maintained in the HR Benefits Section.

Prior leave requests confirmed:

Leave is

Approved

Denied for the following reason(s)

Request approved /denied by: __________________________________________ Date:_________________

• Complete the FMLA Departmental Response to Employee form

• Provide a copy of this form and the Approval/Denial form to the employee

Revised 04/2008

Family And Medical Leave Request Page 2