Jsu Request For Family Medical Leave Act Form (Fmla)
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1
2REQUEST FOR FAMILY MEDICAL LEAVE ACT FORM (FMLA)
Family Medical Leave Act Policy 1:02:17
Employee Last Name
First Name
MI
Employee ID #
Office Phone #
Home Phone #
Home Street Address
City
State
Zip
Email Address
Department
Supervisor Name
Supervisor Email Address
LEAVE REASON
Is this leave related to an
Reason for Leave (choose one):
on the job injury?
⃝ Serious Health Condition of Employee
⃝ Serious Health Condition of Family Member
⃝ Yes
⃝ No
⃝ Military Caregiver
⃝ Pregnancy / Adoption
⃝ Military Qualifying Exigency
⃝ Bonding with newborn, adoption, or foster care placement
If leave is for a qualifying family member
Family member’s name:
Relationship to employee:
(qualifying family members include spouse,
parent, son, daughter, or qualified domestic
partner):
Is spouse a JSU employee?
Spouse’s name:
Were you previously employed by JSU?
If so, when?
⃝ Yes
⃝ No
⃝ Yes
⃝ No
⃝ N/A
If leave is for a child, expected date of
Is the child (whether over or under age 18) incapable of self-care because of a
birth/adoption/foster care placement:
mental or physical disability?
⃝ Yes
⃝ No
⃝ N/A
(mm/dd/yyyy)
LEAVE TERM
Requested Dates of Leave:
Estimated Start Date (First day of absence):
Estimated End Date (Last day of absence):
Type of Leave:
⃝ Continuous (uninterrupted block of time)
⃝ Intermittent (partial and/or periodic days)
BENEFIT(S) CONTINUATION
⃝ I elect to continue
benefits
during
any
unpaid portion of my
⃝ Health
⃝ Dental
⃝ Vision
⃝ Flexible Spending
FMLA leave. Check any
that apply:
Employee Signature / Date:
Supervisor Signature / Date:
This form must be filled out completely, including the supervisor's signature, and submitted to the Department of Human Resources.
hrconfidential@jsu.edu
Page 1 of 2
Form 41
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