City Of Dallas Family Medical Leave Application Form (Page 2 of 5) in pdf

City of Dallas

FAMILY MEDICAL LEAVE APPLICATION

INITIAL APPLICATION

RECERTIFICATION APPLICATION

Part I (Continued) – Required Information

A. EMPLOYEE INFORMATION

Name:

Employee #:

Dept:

Div:

Location & Shift:

Job Title:

Phone #:

Date of Hire:

Supervisor:

Supervisor Phone #:

Dates Leave Requested: Starting

Ending

B. REASON FOR LEAVE

(1)

To care for your spouse, child, or parent with a serious health condition.

Patient’s Name: ___________________________________________

Relationship to employee: _____________

If the requested leave is for a child, please provide age of child _____and D.O.B. ____/____/______

(2)

Your own serious health condition makes you unable to work.

(3)

Birth of a child

Receipt of the placement of a child (by adoption, foster care, etc.)

If the FML request is related to box #3, does your spouse work for the City of Dallas?

Yes

Spouse’s Name:

Department:

C. EMPLOYEE CERTIFICATION

I understand it is my responsibility to notify my immediate supervisor of my need to be off and of the FML dates as soon as I

am aware. If my time entry is via SEA, once approved, it is my responsibility to enter the proper code. I hereby certify that

all of the statements contained herein and attached are true to the best of my knowledge. I understand that omissions or

misstatements may be cause for rejection of my leave request and may result in disciplinary action by the City.

understand that I may be required to use my vacation and sick leave balances during my leave. I understand it is my

responsibility to monitor my leave balances and the City will not notify me when I have exhausted paid leave. Work related

injuries resulting in lost time will be charged to the employee’s existing FML balance. I also understand that the City of

Dallas may recover from me its portion of the health insurance premiums paid during my leave if I fail to return to work for

any reasons other than continuation, recurrence, or onset of a serious health condition affecting myself or immediate family

member.

Employee Signature:

Date:

HUMAN RESOURCES APPROVAL

Employee’s leave request has been reviewed and is:

Approved

Denied for the following reasons:

Untimely/incomplete request

FMLA balance exhausted

Ineligible reason

Other (describe below):

_____________________________________________________________________________________________________________

Human Resources Signature:

Date:

“Dallas, the City that Works: Diverse, Vibrant and Progressive”

HRD Form Rev.June 2006

City Of Dallas Family Medical Leave Application Form Page 2

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