FMLA Request Form

This page to be filled out only for continuous leave requests.

Employee Name / Employee ID #
Home Address / Contact Phone #
City/State/Zip / E-mail Address
EstimatedStart Date of Leave / EstimatedEnd Date of Leave

FMLA TYPE REQUESTED Continuous (several days/weeks in a row) / Intermittent (as needed)

REASON FOR FMLA REQUEST–CHECK APPROPRIATE BOXES

Twelve workweeks of leave in a 12-month period for:

the birth of a child and to care for the newborn child within one year of birth;

the placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement;

to care for the employee’s spouse, child, or parent who has a serious health condition;

a serious health condition that makes the employee unable to perform the essential functions of their job;**

any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on “covered active duty;” or

Twenty-six workweeks of leave during a single 12-month period to care for a covered servicemember with a serious injury or illness if the eligible employee is the servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave).

In addition to this form, DOL Form WH-380-E (Certification of Health Care Provider for Employee’s Serious Health Condition) or DOL Form WH-380-F (Certification of Health Care Provider for Family Member’s Serious Health Condition) must be submitted within 15 (fifteen) calendar days.

I request to use available leave during the period of absence as follows (please specify a number of hours or write ALL in the type of leave you are requesting to use):

Sick Leave / Annual Leave / Personal Leave / Leave Without Pay

EMPLOYEE ACKNOWLEDGEMENT

I acknowledge receipt and understanding of the DPHFamily and Medical Leave Policy (HR-03431) and the terms and conditions of my Family and Medical Leave. I agree to abide by the policy guidelines as a condition of my employment and my continuing employment at the Department of Public Health. I understand that to return to my former position or equivalent position with the same pay and grade, benefits and comparable working conditions is contingent upon compliance with the terms of approved family and medical leave.

** I will have my doctor submit a letter indicating the date I can return to work and list any restrictions to me performing my job.

Employee’s Printed Name / Signature / Date

SUPERVISORS ACKNOWLEDGEMENT

This acknowledges my awareness that my employee is applying for FMLA.

Supervisor’s Printed Name / Signature / Date
Employee’s Name (Print or Type):
This is to request approval of the following leave:
From: / Thru: / Amount of Leave / Type of Leave / Approved
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Leave Codes
FML/A / Family Medical Leave/Annual / FML/P / Family Medical Leave/Personal
FML/S / Family Medical Leave/Sick / LWOP / Leave Without Pay**
SCT / State Compensatory Time / FLSA / FLSA Compensatory Time
REQUESTED BY: / APPROVED BY:
Employee’s Signature / Supervisor’s Signature
Date / Date