FMLA LOG

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					                                     THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON
                                                                          FMLA TIMELOG

Employee: ________________________________________                                     FMLA Calendar Year: ___/___/___ to ___/___/___
EMPID_________________                                                                 Incident: ______________________________________________

                                                                                            PAID LEAVE               UNPAID

                                                                                                                      PREMIUM SHARING
                                                                                FMLA HRS                                ARRANGED?
    FOR        FROM          TO        TIME                          YTD FMLA   REMAINING                    PA                         MISC
   WHOM        DATE         DATE       OUT    TIME IN   # OF HOURS   HRS USED     of 480    SICK    VAC   ENTERED?     YES      NO      INFO




G/Employee Relations/FMLA/FMLA Log
Revised 0403
G/Employee Relations/FMLA/FMLA Log
Revised 0403

				
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