Fill and Sign the Medical Leave Form

Request for Family or Medical Leave Please Note: This Form should be used to request FMLA leave involving intermittent periods of time of or a reduced daily or weekly work schedule. An eligible employee requesting FMLA leave must give thirty (30) days’ advance notice to their supervisor of the need to take unpaid FMLA leave when the need for leave is foreseeable. When the need for leave is not foreseeable, such notice must be given as soon as practicable. The use of FMLA leave will be subject to verifcation. The Company may require that an employee’s request for FMLA leave to care for the employee’s seriously ill spouse, son, daughter, or parent, or due to the employee’s own serious health condition, be supported by a certifcation issued by the health care provider. Name: ______________________________________________________ Date: ________________ Name of Department: _________________________ Title: ______________________ Status: [ ] Full Time [ ] Part Time Date of Hire: _____________________________ Length of Service: ________________________ I am requesting family or medical leave for one or more of the following reasons: [ ] The birth of my child and in order to care for him or her. Expected date of birth: __________ Actual date of birth: _________________ Leave to start: __________ Expected return date: __________ [ ] The placement of a child with me for adoption or foster care. Date of placement: __________ Leave to start: __________ Expected return date: __________ [ ] To care for my spouse, child, or parent who has a serious health condition. Leave to start: __________ Expected return date: __________ Note: A physician's certification may be required for leave due to a serious health condition. [ ] For a serious health condition that makes me unable to perform my job. Describe health condition : _____________________________________________________ Leave to start: __________ Expected return date: __________ Note: A physician's certification may be required for leave due to a serious health condition. 1 Request intermittent leave schedule: (description of schedule). The reason for this notice of a need for intermittent leave or a reduced work schedule is: [ ] For the birth of a son or daughter and to care for that child. [ ] For placement of a son or daughter for adoption or foster care with myself. [ ] To care for my spouse, son, daughter or parent with a serious health condition. [ ] A serious health condition that makes me unable to perform the functions of my job. Note: A physician's certification may be required for leave due to a serious health condition. Have you taken a family or medical leave in the past 12 months? [ ] Yes [ ] No If yes, how many workdays? ___________ I agree to the following provisions: I have worked for the Company at least one year and at least 1,250 hours in the previous 12 months. I f I fail to return to work after the leave for reasons other than the continuation, recurrence or onset of a serious health condition that would entitle me to Medical Leave or other circumstances beyond my control, I will be financially responsible for the medical insurance premiums the company paid while I was on leave. I will be required to exhaust my paid vacation, personal, medical (disability) or sick leave as part of my 12 weeks of leave. After 12 weeks of leave, if I do not return to work or contact my supervisor on the date intended, it will be considered that I resigned from the Company. Dated: _________________ _____________________________________ (Signature of Employee) (Printed Name of Employee) _________________________________ (Signature of Supervisor) ** (Printed Name of Supervisor ) Dated: ________________________ **NOTE: Supervisor’s signature is required for informational purposes only and does not constitute designation or approval of leave as FMLA qualifying leave. 2