University of Wisconsin – Oshkosh
Family & Medical Leave Request Form
Name Social Security Number
Home Address
(city) (state) (zip)
Home Phone Work Phone
Department Current email
Supervisor Supervisor email ______
LEAVE REQUESTED
I request leave from to .
I request intermittent leave according to the following schedule:
I request a reduced schedule leave according to the following schedule:
The total number of days of leave that I request is:
Have you taken an FMLA leave in the past two years? Yes ¨ No ¨
Dates of prior leave: From To .
I am requesting leave for the following reason:
¨ My own personal serious health condition
¨ To care for the serious health condition (Practitioner or Physician certification may be required) of:
¨ Legal Spouse (name: ______)
¨ Child (natural, adopted, stepchild or legal ward)
¨ Parent (natural, foster or adoptive parent of employee) Name: ______
¨ The birth of my child and to care for such child (Expected date of birth: ______)
¨ The placement of a child with me for adoption or foster care (Expected date: ______)
¨ Injured Service-member Leave: Name: ______
¨ Active Duty Family Leave: Name: ______
(Over)
Substitution of Paid Leave: Order of use-Optional
¨ Sick Leave # of Hours/Days
¨ Vacation # of Hours/Days
¨ Personal/Floating Holiday # of Hours/Days
¨ ALRA/Sabbatical # of Hours/Days
¨ Legal Holiday # of Hours/Days
¨ Unpaid Leave # of Hours/Days
Approval / *Disapproval of “use of paid leave, reduced leave and/or intermittent leave”:
______
Supervisor/Chair Date
______
Dean/Division Administrator Date
*If disapproved, indicate the reason: ______
______
Employee Information & Responsibilities
1. Completed leave slips or timecards, with your supervisor’s signature, must be completed and turned in to Human Resources during the time you are on leave. For classified staff, you are encouraged to turn them in prior to beginning your leave.
2. If your FMLA leave will be in pay status it will not require any prepaid insurance premiums. The deductions will automatically be taken from your monthly or bi-weekly earnings.
3. If your FMLA leave will be unpaid, prepaid insurance premiums are required.
4. Please contact Human Resources when you return to work or the dates of your leave change.
5. If the leave is for your own serious medical condition, you are required to obtain and present certification to Human Resources from your physician or practitioner that states you are able to return to work, and any restrictions.
6. While out on FMLA leave, it is agreed that there is no work that shall be done by an employee that is out for their own serious medical condition.
I have read and understand my responsibilities. ______
Employee Signature
Eligible: Yes ¨ No ¨ Leave is: Approved ¨ Denied ¨
Denied for the following reason(s):
Human Resources Signature: ______Date: ______