Medical Leave Request Form

NOTE:For use only with requests for Family & Medical Leave, Family Illness Leave, Voluntary Shared Leave, and/or Leave Without Pay due to medical reasons. Refer to the appropriate policies for more information on eligibility and restrictions. Not for use with routine sick leave.

Date of Request: / Type of Request: / New Request / Supplement to Previous Request
I. EMPLOYEE DATA
Employee Name: / PID:
Dept. Name:
Home Address: / Home Phone:
Email Address:
*Approval is sent by email
Appointment
Information: / Date of Hire: / Permanent / SHRA / Full-Time
Temporary / EHRA Non-Faculty / Part-Time – Hrs./Wk.:
Supervisor Name: / Supervisor Phone:
NOTE: The Supervisor listed above will receive a copy of the employee's leave designation (approval/denial letter).
II. MEDICAL CONDITION INFORMATION
Leave Selections (check all that apply): / Reason(s) for Requesting Leave:
Family & Medical Leave / Serious Health Condition of the Employee
Family Illness Leave / Serious Health Condition of a: Parent Child Spouse Military Family Member
Voluntary Shared Leave (VSL) / Other under VSL:
Military Caregiver/Qualified Exigency
(must also check Family & Medical Leave) / Qualified Exigency for National Guard or Reserves
New Child: Birth Adoption Foster Care Placement
For birth-related leave,
the Medical Certification Form is required only
if the period of medical disability is expected to exceed a typical birth (normally 6-8 weeks). / For Pregnancy:
Expected Date of Birth: / For Adoption or Foster Care:
Expected Date to Begin Care of Child:
III. LEAVE REQUEST
Dates must be provided. Leaving dates blank will delay the processing of your leave request.
If requesting a leave of absence: / Start Date: / End Date:
If requesting a reduced work schedule: / Start Date: / End Date:
Hrs./Week: / Work Schedule:
If requesting an intermittent work schedule: / Start Date: / End Date:
Expected Frequency of Absences:
Expected Duration of Absences:
IV. EMPLOYEE SIGNATURE
Employee’s Signature: / Date:
V. DEPARTMENTAL AUTHORIZATIONS
Supervisors’ Approval for Medical Leave: / YES NO / Supervisor’s Approval for
Shared Leave (VSL): / YES NO
Additional Supervisor Comments: / Indicate the number of VSL hours employee is authorized to receive:
VSL is paid by the recipient’s department (not the donor’s) and must be authorized by the supervisor. Departments may limit the amount of VSL hours that will be awarded to individuals per event and/or per leave year, must notify employees of this in advance, and must apply the limit consistently.
Supervisor’s Signature: / Date:
2nd Level Supervisor Signature (Optional): / Date:
VII. ROUTING OF DOCUMENTATION
Return the completed Medical Leave Request Formalong with the Medical Certification Form (if applicable), Leave Records, and any other supporting documentation to the UNC General Administration Benefits Office.
•Fax to (919) 843-8945
•Mail or hand-deliver toUNC General Administration Human Resources, Benefits, 140 Friday Center Drive, Chapel Hill, NC 27517
QUESTIONS? Please contact the Benefits Office at (919) 843-5186.
VIII. FOR HR OFFICE USE ONLY
Family & Medical Leave: / Approved / Denied / N/A
Continuous / Intermittent / Reduced Schedule
Family Illness Leave: / Approved / Denied / N/A
Continuous / Intermittent / Reduced Schedule
Voluntary Shared Leave: / Approved / Denied / N/A
Continuous / Intermittent / Reduced Schedule
Military Exigency Leave: / Approved / Denied / N/A
Continuous / Intermittent / Reduced Schedule
Additional Comments:
Signature (HR Rep): / Review Date:
REFERENCE: Employee Last Name: / Employee PID:

Rev. 11-16-2016Equal Opportunity EmployerPage 1 of 2