FMLA Leave Request

Leave Eligibility

In order to be eligible for 12 weeks of unpaid leave under the FMLA, every 12 months you must meet BOTH

of the following requirements:

1)You have worked at {INSERT COMPANY NAME} for 12 months or more (12 months does not need to be consecutive).

2)You have accrued a minimum of 1250 hours (approximately 8 months based on a 40 hour work week or 1 year based on a 25 hour work week) in the last 12 calendar months.

Please select one of the following:

____Yes, I meet both requirements

____No, I do not meet both requirements

Previous Leave Information

Have you ever taken leave under the Family and Medical Leave Act?

YES_____     NO_____

If yes, please provide the dates of leave and the reason for the leave below.

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Have you ever taken a leave that was not under the Family and Medical Leave Act?

YES_____     NO_____

If yes, please provide dates of leave and the reason for the leave below.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Reason For Leave Request

Select reason for leave request under the FMLA:

For a serious personal health condition:

Does your health condition require a 3 day absence from work and/or an overnight stay

at a medical clinic? YES_____     NO_____

Describe condition below:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

To care for a spouse, child or parent with a serious health condition:

Name of family member:_____________________________________________

Relationship to you:_________________________________________________

If the family member is a child, is he/she under 18 years of age?

YES_____     NO_____

Does the family member´s condition require a 3 day absence from normal

life activities (work, school, etc) and/or an overnight stay at a medical facility?

YES_____     NO_____

Describe condition below:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

To attend the birth, adoption, or foster placement of a child.

Provide expected date of birth, adoption, or foster placement.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Description of Requested Leave

Dates of requested leave:_________________________

Total leave time:________________________________

Is this request for an intermittent leave?             YES_____     NO_____

If yes, describe below the proposed schedule.

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Is this request for a reduced work hour leave?        YES_____     NO_____

If yes, describe below the proposed schedule.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Are you requesting that paid leave be substituted for unpaid FMLA leave?

YES_____     NO_____

If yes, name the paid leave you wish to substitute.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Employee Statement

I agree to return to work on {ENTER DATE MM/DD/YYYY}.Should circumstances change,

I agree to notify my employer {INSERT COMPANY NAME} in writing as soon as possible.

I agree to provide my employer with any requested medical certification that is permitted under the clauses of the Family and Medical Leave Act of 1993.I understand that my employer, {INSERT COMPANY NAME}, will continue to pay my health care benefits, but that payment for all other benefits will be suspended until I return to work.I understand that the continuation of my health care benefits is contingent upon my continue payment for my regular health care deductions.

I acknowledge that I have read and understood the Notification of Employee FMLA Rights given to me by my employer.

________________________

Print Name

________________________

Signature

________________________

Date

For Office Use Only

General Employee Information

Start Date:{MM/DD/YYYY}

End Date:{MM/DD/YYYY}

Hours worked per day:________________________

Days worked per week: ________________________

Total hours worked per week: ___________________

This schedule began on:{MM/DD/YYYY}

Leave Approval

Employee´s requested leave is approved.

1)Select one of the following:

Intermittent Leave

Reduced Schedule Leave

Describe below:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

2) Will the employee need to provide medical certification during the leave?

YES_____

NO_____

If yes, describe below:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

3) Return to work date:{MM/DD/YYYY}

Employee´s requested leave is denied.

Provide reason for refusal below.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Request approved/denied by:

_________________________________________________

Print Name/Signature

_________________________________________________

Position/Date