EMPLOYEE APPLICATION FOR FAMILY OR MEDICAL LEAVE OR FAMILY MILITARY LEAVE
Name_______________________________ ID No.:_______________ Department:
Date of Hire: ______________Authorized Hours per pay period :
Name of Supervisor
Complete and return this form within 2 calendar days of the beginning of your leave. Complete all areas. Keep a copy for
The Certification of Health Care Provider OR Attending Physician Statement form must be completed and submitted to
Human Resources within 15 days of notification from Human Resources. The person with the serious medical illness
must be seen in person by the healthcare provider within 7 calendar days from the first day of incapacity.
Refer to the reverse side of this form and Policy and Procedure 45-21, “Family and Medical Leave and Other Absences”, for
Short-Term Disability (STD): If you are going to be off more than 32 hours for your own medical illness and
your authorized hours are 40+ per pay period, you need to apply for STD. Forms are available in Human
Resources and we can use the Medical Certificate from UNUM for both STD and FMLA. While receiving
STD pay if you do not want Deaconess to supplement the 40% not paid by UNUM using your PTO accrual
please notify Human Resources.
Beginning Date of Absence:
Return to Work Date:
Why are you applying for family or medical leave?
I am applying for Employee Medical Leave (employee’s serious health condition, worker’s compensation, or
I am applying for short-term disability
I am applying for Family Medical Leave to care for a spouse, child or parent.
I am applying for Family Leave (extension of maternity leave to care for newborn child or to care for adopted
or foster child).
I am applying for family military leave
I am not applying for a leave (will count as an occurrence of absence).
I am applying for Intermittent Medical Leave due to a chronic condition. State the medical reason for
Intermittent Medical Leave:
Are you a salaried supervisor?
Authorization and Signature: I understand that a health care provider, a human resources professional, or a
leave administrator representing Deaconess may contact my physician for clarification and authentication of
the medical certification. I understand the terms and conditions of a leave as stated in this document and
hospital P&P 45-21, “Family and Medical Leave and Family Military Leave.”
Please see the reverse side of this form for additional information regarding the FMLA.
FOR HUMAN RESOURCES USE ONLY:
Hours worked: ___________ As of PPE: ______________ NonFMLA Weeks: ________
No Date: __________ Intermittent Date: _________ Requests:
Time used in Past 12 Months: FMLA: _____ Weeks _____ Hours /
NonFMLA: ______Weeks ____Hours PPE:________