FMLA Employee Request Form

FMLA Employee Request Form
To request leave on the basis of the Family and Medical Leave Act (FMLA), please complete the following request form and submit it at least 30 days prior to leave (unless leave is unforeseen, in which case submit the form as soon as practical).
Employee Name:
Location of Employeement:
Requested Leave Start Date:

MonthDayYear
Date
Estimated End Date:

MonthDayYear
Date
The reason for this FMLA leave request is (select the most appropriate box):
Time off work is expected to be (select the most appropriate box):
Additinal information about employee FMLA rights and responsibilities will be provided to you in writing within five business days after receipt of this notice (unless already provided).

Determination of eligability for leave under the FMLA, and/or additional documentation or clarification of documentation, may be required prior to making a final FMLA determination to approve or deny an FMLA leave request. Please contact Sara Gibson with any questions.
Employee Signature:
Date & Time Submitted:
Should be Empty: