Leave Request Form - Family Leave printable pdf download

Leave Request Form – Family Leave

Name:__________________________________________

Employee Number:___________________________

Organization:____________________________________

HR Rep/Consultant:__________________________

PLEASE CHECK TYPE OF LEAVE REQUEST:

☐ This request is for Family Leave.

☐ Due to Birth; Baby due date: _____/_____/_____ (Return DOL WH-380-F)

☐ Due to Adoption/Foster Care (Attach copy of adoption/foster care papers)

☐ To care for a family member with a Serious Health Condition (Return DOL WH-380-F)

Full Name of Family Member____________________________________________________________

Relationship:

☐ Spouse

☐ Child

☐ Parent

☐ Sibling

☐ Grandparent

☐ Other dependent household member/individual

(Employee must submit proof of such support by providing Affidavit for “Other” Dependents.)

☐ Domestic Partner

(Employee must file Affidavit of Domestic Partner Relationship.)

DURATION OF LEAVE REQUEST:

☐ I will need to be absent for a single continuous period of time.

Start Date: _____/_____/_____

End Date: _____/_____/_____

Return to Work Date: _____/_____/_____

☐ I will need to be absent intermittently

(NOTE: Intermittent leave is NOT available following birth, adoption or foster care placement)

☐ This request is for Vacation.

If you wish to incorporate any vacation days into your overall leave plans, please outline how you wish to take any

vacation day(s) in the space provided below:

SIGNATURE STATEMENT:

I hereby request a Family Leave without pay for the period and reason as submitted on this form. I have read and understand

the conditions that will apply to this Leave. By signing below, I give my consent to the authorized Company representative (but

NOT my immediate supervisor) to contact my family member’s healthcare provider regarding clarification and authentication

of the medical reasons for this Leave, as applicable. I acknowledge that for any Family Leave which would exceed the legal

entitlement of 12 workweeks within a 12-month period, there is no right to job reinstatement at the conclusion of the leave.

Name:_________________________________________________________________ Date:_____/_____/_____

Leave Request Form - Family Leave