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Request For Leave Under The Family And Medical Leave Act Of 1993 (Fmla) - Massachusetts Bay Transportation Authority

Massachusetts Bay Transportation Authority

Mitt Romney

Kerry Healey

John Cogliano

Daniel A. Grabauskas

Governor

Lt. Governor

Secretary and MBTA Chairman

General Manager

Revised 02/01/06

Request For Leave Under

The Family and Medical Leave Act of 1993 (FMLA)

EMPLOYEE’S

SERIOUS HEALTH CONDITION

FMLA – Page 1 to be completed by employee

Name __________________________________________ Employee # ___________________

Address ______________________________________________________________________

NUMBER

STREET

CITY

STATE

ZIP

Home Phone: __________________________________________________________________

Job Title ________________________________________

Date of Hire _________________

Department _____________________________________

Area # ______________________

Please check the qualifying reason for your FMLA request:

Employee’s serious health condition (including prenatal conditions):

*Maternity/Childbirth - Estimated Date of Delivery ________________________

*Adoption/Foster Care - Estimated Date of Event ___________________________

*If I am applying for coverage for childbirth, adoption or foster care placement, I also am applying for any benefits I

may be entitled to under the Massachusetts Maternity Leave (MML). If eligible for leave under FMLA, and/or the

MML, I understand that the Authority shall apply any leave entitlement concurrently, unless otherwise designated by

the Authority.

By signing this form I am authorizing the release of medical information related to my FMLA

request to the Massachusetts Bay Transportation Authority.

Employee’s Signature:____________________________________________ Date: _____________________

Massachusetts Bay Transportation Authority, Ten Park Plaza, Boston, MA 02116-3974

Request For Leave Under The Family And Medical Leave Act Of 1993 (Fmla) - Massachusetts Bay Transportation Authority