Request for Family or Medical Leave Request for Family or Medical Leave Please Note This Form by pellcity27

VIEWS: 87 PAGES: 2

									                            Request for Family or Medical Leave


Please Note:
This Form should be used to request FMLA leave involving intermittent periods of time off or a
reduced daily or weekly work schedule. An eligible employee requesting FMLA leave must give
thirty (30) days’ advance notice to their supervisor of the need to take unpaid FMLA leave when
the need for leave is foreseeable. When the need for leave is not foreseeable, such notice must
be given as soon as practicable. The use of FMLA leave will be subject to verification. The
Company may require that an employee’s request for FMLA leave to care for the employee’s
seriously ill spouse, son, daughter, or parent, or due to the employee’s own serious health
condition, be supported by a certification issued by the health care provider.

Name: ______________________________________________________

Date: ________________

Name of Department: _________________________               Title: ______________________

Status:         [   ]   Full Time    [   ]   Part Time

Date of Hire: _____________________________

Length of Service: ________________________

I am requesting family or medical leave for one or more of the following reasons:

[   ]     The birth of my child and in order to care for him or her.
Expected date of birth: __________ Actual date of birth: _________________
Leave to start: __________ Expected return date: __________
[   ]     The placement of a child with me for adoption or foster care.
Date of placement: __________
Leave to start: __________ Expected return date: __________
[   ]     To care for my spouse, child, or parent who has a serious health condition.
Leave to start: __________ Expected return date: __________
Note: A physician's certification may be required for leave due to a serious health condition.
[   ]     For a serious health condition that makes me unable to perform my job.
Describe health condition: _____________________________________________________
Leave to start: __________ Expected return date: __________
Note: A physic
								
To top