request for fmla leave
REQUEST FOR FMLA LEAVE When possible, employee should give verbal or written notice to make employer aware that leave is needed 30 days prior to need. If leave is not foreseeable, employee should give notice as soon as possible. Please complete this form and return it to Julie Rogers, Human Resources Asst., at the District Office. In general, to be eligible an employee must have worked for an employer for at least 12 months, have worked at least 1,250 hours in the 12 months pr eceding the leave, and work at a site with at least 50 employees within 75 miles. You will be required to furnish certain necessary information and/or medical certification as needed. Designation becomes final if and when an FMLA qualifying event is confir med. You will be notified in writing of the results of this request. If you have questions or need further information please contact Julie Rogers at (316) 733-3624, or email [email protected]. NOTE: An employee requesting leave for the employee’s serious health condition or the serious health condition of the employee’s spouse, child, or parent must submit a verifying medical certification from a physician within 15 days of request for leave.
Employee Name:
SSN:
Home Address: Home Phone:
Cell Phone:
Building or Dept.: Job Title:
Supervisor:
Is this a work-related injury/illness? ______ Yes ______ No Reason for Leave:
Birth/Adoption/ Foster Care
My own serious health condition
Family member’s serious health condition (Relationship to family member )
Family member called to active duty/caring for a covered service member with a serious injury or illness (Relationship to service member )
Notes: Leave Requested From
to
Intermittent? (Y/N)
I hereby certify that the information given above is true and correct to the best of my knowledge. I understand that misrepr esentation or omission of the reason for leave or any of the facts supporting the need for leave will result in denial of the leave and will subject me to discipline up to and including termination.
Employee Signature
Date HR USE ONLY
Leave Approved (Y/N) _____ REMARKS:
Expected Return Date _______________
Initial __________
Date _____________
Employee Name:
SSN:
Home Address: Home Phone:
Cell Phone:
Building or Dept.: Job Title:
Supervisor:
Is this a work-related injury/illness? ______ Yes ______ No Reason for Leave:
Birth/Adoption/ Foster Care
My own serious health condition
Family member’s serious health condition (Relationship to family member )
Family member called to active duty/caring for a covered service member with a serious injury or illness (Relationship to service member )
Notes: Leave Requested From
to
Intermittent? (Y/N)
I hereby certify that the information given above is true and correct to the best of my knowledge. I understand that misrepr esentation or omission of the reason for leave or any of the facts supporting the need for leave will result in denial of the leave and will subject me to discipline up to and including termination.
Employee Signature
Date HR USE ONLY
Leave Approved (Y/N) _____ REMARKS:
Expected Return Date _______________
Initial __________
Date _____________
