Tech Valley Sport High School Leave Request Under Fmla printable pdf download

LEAVE REQUEST UNDER FMLA

Employee Name: _________________________

Date of Request: ____________

Position: _______________________

Supervisor: ____________________________

I request leave under FMLA for the following reason (check one):

___ A.

To care for my child after birth or placement for adoption or foster care.

___ B.

In order to care for a spouse, child or parent with a serious health condition (Please

submit a "Certification of Health Care Provider for Family Member’s Serious Health

Condition,” Form WH-380-F, with this request).

___ C.

For my own serious health condition that makes me unable to perform the functions

of my job. (Please submit a “Certification of Health Care Provider for Employee’s

Serious Condition,” Form WH-380-E, with this request).

___ D.

For a qualifying exigency arising from the fact that my spouse, child or parent is on

active duty or called to active duty. (Please submit a “Certification of Qualifying

Exigency for Military Family Leave,” Form WH-384, with this request).

___ E.

To care for a covered servicemember who is my spouse, child, parent or other next of

kin and who has a serious injury or illness. (Please submit a “Certification for

Serious Injury or Illness of Covered Servicemember for Military Family Leave,” Form

WH-385, with this request).

METHOD OF LEAVE REQUESTED

___ A.

Consecutive Leave (e.g., an uninterrupted time period) for _________ (days/weeks).

___ B.

Intermittent or Reduced Leave Schedule (e.g., every Tuesday and Thursday for an 8

week period)

Specify below the exact nature of your requested intermittent or reduced leave:

______________________________________________________________

Date leave is to begin: __________

Date leave is to end: _______________

Expected duration of leave: ____________________________________________

________________________________

Employee Signature

________________________________

Date

Tech Valley Sport High School Leave Request Under Fmla