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

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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

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