Fmla Questionnaire Form
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5Date:_________________
FMLA Questionnaire
Requested Start Date:
______________________________________
Name:_______________________________
Address:_____________________________
City:_____________________
State:____________
Zip:____________
Home Phone number: ________________
Hire Date: ____________
Badge Number: ____________
Department: ___________
Shift: _______
Supervisor: _________________________
Job Functions (circle one):
Other: __________________
heavy equip op
maint custodian
overhd crn opp
mtrl cntrl
pipefitter
welder sheetmetal
insulation mech
struc welder
maint elec
fab tech
sheetmetal shop
outside mach
optical tool
otsd elec
carpenter
sheetmetal non-shop
shipfitter
inside mach
pipe welder
inspector
paint
Reason For Your FMLA Request: Please circle one
Own Health Condition
Your Legal Spouse
Your Child
Your Parent
Your In-Law Parent
Birth of a child (Are you legally married? Please circle: YES
NO)
Adoption of a child
Personal E-mail Address: ___________________________________________
Employee Signature:__________________________________ Date Signed: ________________
Rev 3/1/16
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Parent category: Business