FMLA Leave Notification Form
Use this form to notify HR of a potential FMLA-qualifying leave. Submission of this form does not guarantee approval. HR will review eligibility and follow up with required documentation.
Employee Information
Employee Name
*
First Name
Last Name
Employee Email
*
example@example.com
Supervisor Name
*
First Name
Last Name
Supervisor Email
*
example@example.com
Basic Leave Information
Anticipated Start Date
*
-
Month
-
Day
Year
Date
Anticipated End Date
-
Month
-
Day
Year
Date
Is this leave expected to be
*
Continuous (one block of time)
Intermittent (occasional days/hours)
Reduced schedule
Reason for Leave (Select the best fit)
*
Employee's own serious health condition
To care for a spouse, child, or parent with a serious health condition
Birth of a child
Placement of a child for adoption or foster care
Qualifying military exigency
To care for a covered service member with a serious injury or illness
Other
Family Member's Relationship to Employee
*
Spouse
Child
Parent
Other
Brief Description (Do not include detailed medical information)
*
Submit
Should be Empty: