Fill and Sign the Opm Form 71 Download Fillable PDF Request for Leave or

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
7. Prior work schedule? Or 8. Have you had any pay interruptions? Yes no (if ‼yes,” resume at next question. If ‼no,” stop here.) 9. Have you completed any leave-taking education courses offered by the company? Yes/no: 10. Have you received training, supervision, or other professional assistance for leave? Yes no 11. Have you participated in any career counseling (including job search and interview assistance)? Yes no 12. Any other medical, medical assistance, or family assistance? yes/no: [additional comments regarding health care and disability: if you work at a company with more than 10 employees, your employer is required by the FMLA to provide notice to those employees. However, if your employer provides less notification, you are exempt from this notice requirement.] [additional comments regarding the use of accrued sick days] you must use the available sick leave for leave that is granted for a covered FMLA absence and any other health care related absences. You may also use sick leave for other purposes not related to a covered FMLA absence; however, no sick leave may be used for a covered FMLA absence unless it is taken to maintain your health, unless this is necessary to treat or prevent an imminent risk to your health, or unless required by the federal family and medical leave act of 1993 (FMLA) to care for a family member with a serious health condition (for example, if a close relative has a serious illness, and you are unable to care for them on your own) that requires medical treatment of the family member, and must be paid under the family and medical leave act (FMLA). You may also use sick leave for other purposes not related to a covered FMLA absence; however, no sick leave may be used for a covered FMLA absence unless it is taken to maintain your health, unless this is necessary to treat or prevent an imminent risk to your health, or unless required by the federal family and medical leave act of 1993 (FMLA) to care for a family member with a serious health condition (for example, if a close relative has a serious illness, and you are unable to care for them on your own) that requires medical treatment of the family member, and must be paid under the family and medical leave act (fmla). An employer or business may not require you to use your vacation accrued sick time or unused sick hours, your paid vacation