Family and Medical Leave (FMLA) Request Form

MSU Department of Human Resources

Family and Medical Leave (FMLA) Request Form

In general, to be eligible an employee must have worked for the university for at least 12 months, and for at least 1,250 hours during the 12 months preceding the start of the FMLA leave. Employees are expected to give as much advance notice as possible when requesting FMLA leave and to make all reasonable efforts to minimize the disruption caused by their absence. The employee is required to substitute any available accrued paid leave for any part of the applicable leave provided under the Family Medial Leave Act.

Refer to MSU Family Medical Leave Policy # 3.341

http://personnel.mwsu.edu/policy/3.3-employee-policies/3.341-Family_Med_Leave.asp

Name:______

Home Address: ______

(City) (State) (Zip)

Home Telephone: ______Work Telephone: ______

Department: ______Supervisor: ______

I am requesting FMLA as: (check one)

1.______Continuous leave under the care of a licensed practitioner during a prolonged period of incapacity or convalescence due to a catastrophic illness, or

2.______Intermittent leave or reduced work schedule for a chronic, severe medical condition requiring recurrent treatment by a licensed practitioner.

The employee is required to furnish a written statement from the licensed practitioner to substantiate the need for intermittent leave and whether leave will be taken as needed or on a set schedule.

Purpose of Leave (Check one)

ð Employee’s Personal Illness/ Type of Illness______

ð Childbirth ð Adoption ð Foster Child Anticipated date ______

ð Care of Seriously Ill Family Member (Employee’s Parent, Spouse, Child)

Name of Family Member ______Relationship______

Type of Care Required ______

______

ð Care for a Covered Service Member ð For Qualifying Exigency for Military Family Leave

FMLA Beginning Date ______FMLA Ending Date ______

An employee who has been on FMLA leave for more than 3 consecutive days due to his or her own serious health condition is required to provide medical certification of fitness for duty before returning to work.

I certify that the information above is accurate. I understand that I may have to provide necessary medical documentation for any period of FMLA requested and that I will need to notify my department and/or Human Resources immediately if any of the information above should change.

Employee ______Date ______

As the supervisor of the employee listed above, I am aware that the employee has applied for a Family Medical Leave Act leave. I will notify the Office of Human Resources immediately if I become aware of any changes to the information above.

Supervisor ______Date ______

Return completed form and proper documentation to:

MSU – Human Resources Dept

Hardin Administration Bldg, Rm 210

Phone (940)397-4207 Fax (940)397-4780

4-23-09