Fill and Sign the Family Medical Leave Form

Employee/Department Head Application for FMLA LeaveDepartment of Human ResourcesEmployee Name: Date: Department: Division: Title: Date of Hire: Subject: Application for Family Medical Leave of AbsenceDate Leave to begin: Return to work date: Qualifying Reasons for Leave: The birth of a child, or the placement of a child with you for adoption or foster careA serious health condition that makes you unable to perform the essential functions of your job; orA serious health condition affecting your spouse, child, parent, for which you are needed to provide care. I understand that, if qualified, I have the right under the FMLA for up to 12 weeks of paid and/or unpaid leave in a 12-month period for the reasons listed above. Also, my health benefits must be maintained during any period of unpaid leave under the same conditions as if I continued to work, and I must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on my return from leave. It is anticipated that I will return to work upon completions of this leave of absence. It is understood that if I elect not to return to work at the end of this leave, I will be charged the full COBRA amount for all health insurance coverage during any unpaid portion of FMLA leave.I also understand that this time is to be taken as paid time, utilizing accrued sick, vacation and personal leave running concurrently with FMLA leave time until the paid leaves are exhausted. FMLA leave may include unpaid time once accrued paid leave time is fully utilized, or if I have no accrued leave time balances.Human Resources Policy _____ (Family Medical Leave of Absence) more fully describes the terms and conditions for a Family Medical Leave of Absence (FMLA).Signature of requesting party: Date: Original to be sent to the Director of Human Resources.