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Human Resources

FMLA Request Form

EMPLOYEE INFO:
SUPERVISOR INFO:
REASON FOR LEAVE:

Please note: In order to take FMLA leave to care for a child over the age of 18, the child must be “incapable of self-care because of a mental or physical disability at the time FMLA leave is to commence.”

ESTIMATED LENGTH OR FREQUENCY OF LEAVE:
Enter amount of hours per day, week, or month.

Provide a time frame during which you will be continuously absent from work:

Enter amount of hours per day, week, or month.

After receiving this request, an HR Leave Specialist will contact you as soon as possible to set up a brief 15 to 30 minute in-person meeting to discuss additional required FMLA forms and processes.

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