Request For Leave Form (Completed By The Employee) printable pdf download

Request for Leave Form

Please return to

(Completed by the Employee)

Risk Management at

(414) 223-1960 (fax)

within 1-business day.

IT IS YOUR RESPONSIBILITY TO

(414) 278-2921 (office)

FOLLOW YOUR DEPARTMENTAL

CALL-IN PROCESS

To be completed by employee and submitted to Risk Management as soon as possible. Incomplete forms will not be processed.

Employee Name:

Hire Date:

Hours Worked per Week:

Street Address:

Home Phone:

(

)

City:

State:

Zip Code:

Work Phone:

(

)

Supervisor’s Name:

Department:

Work Shift:

Length of Leave: (If your schedule is not Monday through Friday, please attach your work schedule to this form.)

First Day Off: ___________________________

Last Day Off: _______________________________

Return to Work Date: ________________________________________________________________________

If taken intermittently or as a reduced schedule, describe the amount of time needed for this leave and expected

duration for needed leave: ____________________________________________________________________

Type of Leave Requested:

Medical leave for employee’s own serious health condition

(Medical Certification Required)

Family leave for immediate family member with a serious health condition

(Medical Certification Required)

Family leave for bonding ("No medical certification required. However, you are required to submit verification

that you have a new baby in your family. Such verification can consist of a simple statement from you of the

family relationship, your child's birth certificate, a court document, or Milwaukee County insurance records

noting the addition of your child.")

Placement of child for adoption

(Court Documentation Required)

Placement of a child for foster care

(Court Documentation Required)

For leave to care for an immediate family member, please indicate the following:

Full name of the person: _________________________________________________________________

Relationship to employee: ________________________________________________________________

If the person is your child, specify date of birth: ________________________________________________

Please specify what type of time should be used during the state unpaid FMLA benefit, check all that apply:

Sick Allowance (____ hrs.)

Vacation (____ hrs.)

Holiday (____ hrs.)

Personal (____ hrs.)

Unpaid (____ hrs.)

Compensatory Time (____ hrs.)

An employee may choose what earned time off should be used to supplement pay while on state FMLA benefit (the

first two weeks of the leave, or six weeks, if for birth or bonding). After the state benefit has expired, Milwaukee

County will supplement pay by using all available time in the following order: Sick allowance, vacation pay, holiday

pay, personal allowance, and compensatory time. After all time is used, the remaining time will be unpaid. If the

employee has compensatory time available, he/she may select to use it instead of taking time unpaid.

An absence due to a work related injury covered by Injury Pay or Worker’s Compensation will be designated as a FMLA leave

assuming the employee is eligible for FMLA benefits.

You will be notified of the designation of time in writing.

- OVER -

FMLA-02 (Rev. 01/11)

Request For Leave Form (Completed By The Employee)

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