CITY OF FITCHBURG
Family and Medical Leave Act (FMLA) Request Form
To be completed by employee
Employee
Name:
Department
Job
Title:
Employee
ID #:
Initial Application
Home Phone:
Cell Phone:
Reason for Leave of Absence
Own illness (not work related)
Care for ill parent/spouse/child
OTHER/SPECIFY:
Pregnancy disability
Care for newborn/adopted child
Date of Birth or Placement:
Answer all:
Do you have City medical insurance?
Do you have City dental insurance?
Do you have other City insurance(s)?
Are you currently on another leave?
Have you or will you be filling a
Disability insurance claim?
Requested start date
Anticipated end date
Dates of Rolling and/or Intermittent Leave OR reduced work schedule hours:
An FMLA leave of absence is a leave without pay. Paid leave (using accrued sick time, vacation or PTO hours) shall be
substituted for the unpaid leave in accordance with the Family Medical Leave Act Policy.
I understand that I am required to use accrued paid leave, with sick leave to be used first,
until leave concludes or accrued balance is depleted. Below is an estimate of paid
time off available in my account.
Date Begins
(mm/dd/yy)
Date Ends
(mm/dd/yy)
Accrued Sick leave
Accrued Vacation leave
Accrued Personal leave
Employee’s Signature:
Date:
I understand that I am required to complete a FMLA Leave Certification of Health Care Provider form and submit the form to
Human Resources before my leave commences. I understand that if my leave is approved, my time away from work will be
charged against my 12 week leave maximum under FMLA. Upon approval of this requested leave, I am required to utilize all paid
time available to me prior to going into an unpaid leave status. In the event that I go into an unpaid status while on leave, I
understand that I must contact Human Resources to make arrangements to pay my portion of health insurance premiums.
The following forms, if checked, are required to be completed and returned to Human Resources:
Certification of Health Care Provider: This form is to be completed by either my health care provider (if this
leave is for my own serious health condition) OR by my family member’s health care provider (if this leave is
for the serious health condition of a spouse, parent, or child). My physician must complete this entire
form. Failure to complete this form may delay or prevent my leave approval.
Insurance Disclosure Agreement: This is an agreement between my employer and myself to continue my
insurance benefits while on FMLA leave and a financial arrangement for my portion of health care premiums.
Accrued Balances: This printed record is obtained from the department employee who completes your Departmental
payroll. It must include your accrued balances for personal, sick and vacation time, as of the date of your
completion of this Leave Request form.
Request to Return From FMLA Leave: I should fill out the top portion of the form, notifying Human Resources
of the date of my return. For my own serious health condition, the bottom portion of the form (fitness-for-
duty certification) should be filled out by my Health Care Provider and returned to Human Resources NO
LESS than 3 business days prior to my return to work.
I understand that the Certification of Health Care Provider form should be returned to Human Resources
within 15 days. If I am not able to return the form within the allowed time frame, I will contact Human
Resources for assistance.
If this information is not received in the required time frame, my leave will be considered unauthorized.
Employee Signature
Date
Print Name
Rev. 08.06.2019/SDA
PERSONAL
E-Mail Address:
Home
Address:
or
click to sign
signature
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click to sign
signature
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