Fill and Sign the Form Fmla Printable

Family and Medical Leave Request Form Date: ________ Employee Name: _________________________ SSN #: ____________________________ Job Title: _______________________________ Supervisor: ___________________________ Under the Family and Medical Leave Act eligible employees are entitled to up to twelve weeks of unpaid, job-protected leave for certain family and medical reasons. When possible, submit this request form to your supervisor at least 30 day before the leave is to commence. When submission 30 days in advance is impossible due to unavoidable circumstances, submit the request as early as is possible. When permitted under state or federal law, employer may deny or postpone leave for failure to give appropriate notice. ELIGIBILITY 1. Counting any periods of time that you worked for the company (whether they were consecutive or not) have you worked for the company for a total of 12 months of more? YES NO (If “yes,” continue to next question. If “no,” stop here.) 2. During the past 12 months, have you worked at least 1,250 hours? (approximately eight months of 40-hour weeks or one year of 25-hour weeks)? YES NO (If “yes,” continue to next question. If “no,” stop here.) 3. Have you previously received medical or family leave? If yes, provide information below: Dates of leave: From _________________________ To _________________________ 4. Purpose of Leave: _______________________________________ 5. Have you taken any intermittent leave? YES NO 6. Have you taken time off from scheduled hours? YES NO If “yes” provide details: __________________________________________________ REASONS FOR REQUESTING LEAVE: I am requesting leave for the following reason (Circle one): Personal serious health condition Serious health condition of: Spouse Name:                                                             Child Name:                                                             Parent Name:                                                             Birth of a child Expected delivery date is:                                                 Adoption or placement of a child for foster care Child's name:                                                             Scheduled date of adoption or placement: ____________________________ DATES OF 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 requested                               . EMPLOYEE STATEMENT: I agree to return to work on                               . If circumstances change, I agree to inform my supervisor by submitting a NOTICE OF CHANGES IN APPROVED MEDICAL OR FAMILY LEAVE form. I understand that my benefits will continue during my leave and that I will arrange to pay my share of applicable premiums. Signature:_______________________________________________ Date: _________ TO BE COMPLETED BY SUPERVISOR Staff member was hired on                               He/she started in this department on                               Staff member is: FULL-TIME PART-TIME Regular hours are       hrs on       days of the week for a total of       hours per week. Schedule commenced on             Are there 50 or more employees within 75 miles of the facility where employee works? YES NO Has the workforce been this large for at least 12 months? YES NO How will the staff member's duties and responsibilities in your unit be handled during his/her leave of absence?                                                                                                                                                                               Employee has previously requested family or medical leave on                         Leave taken from             to             Total time taken             Supervisor:                                                 Title:                               Date:                                     Telephone #:                                     TO BE COMPLETED BY HUMAN RESOURCES Prior leave requests confirmed:                                                 Leave is: APPROVED DENIED for the following reason(s): ________________________________________________________________________ ________________________________________________________________________ Request approved /denied by: _______________________________________________ Date: _________