Alabama A&M University Family and Medical Leave Act (FMLA) Employee Leave Request Form
Office of Human Resources July 2016
Page 2 of 2
Type of Leave Requested:
Consecutive Start date End date Return to work date
Intermittent
i
Start date End date Return to work date
Reduced Leave Schedule
Have you taken leave under FMLA policy during the past twelve (12) months?
No Yes From to
Employee Statement:
I certify that the statements made above are true and accurate. I understand that I have an obligation to
respond to any questions from the Director of Human Resources at Alabama A&M University designed to
determine whether my absence is potentially FMLA-qualifying. Furthermore, I understand that if I fail to
respond to any reasonable inquiry by the Director of Human Resources regarding this leave request,
Alabama A&M University may deny my FMLA leave request if the Director of Human Resources is unable
to determine whether the leave is FMLA-qualifying.
Signature: Date:
Address:
Contact number: (Home) (Cell)
Return this FMLA Employee Leave Request Form in person to:
Cheryl K. Johnson, Assistant Director, Office of Human Resources
449 Buchanan Way, Normal Alabama
Or mail to:
Human Resources, Alabama A&M University, Normal, Alabama 35762
i
a)Definition . FMLA leave may be taken “intermittently or on a reduced leave schedule” under certain circumstances. Intermittent leave is FMLA leave taken in separate blocks of time due to a single qualifying reason. A
reduced leave schedule is a leave schedule that reduces an employee's usual number of working hours per workweek, or hours per workday. A reduced leave schedule is a change in the employee's schedule for a period of
time, normally from full-time to part-time.
b) Medical necessity . For intermittent leave or leave on a reduced leave schedule taken because of one's own serious health condition, to care for a parent, son, or daughter with a serious health condition, or to care for a
covered servicemember with a serious injury or illness, there must be a medical need for leave and it must be that such medical need can be best accommodated through an intermittent or reduced leave schedule. The
treatment regimen and other information described in the certification of a serious health condition and in the certification of a serious injury or illness, if required by the employer, addresses the medical necessity of
intermittent leave or leave on a reduced leave schedule. Leave may be taken intermittently or on a reduced leave schedule when medically necessary for planned and/or unanticipated medical treatment of a serious health
condition or of a covered servicemember's serious injury or illness, or for recovery from treatment or recovery from a serious health condition or a covered servicemember's serious injury or illness. It may also be taken to
provide care or psychological comfort to a covered family member with a serious health condition or a covered servicemember with a serious injury or illness.
(1) Intermittent leave may be taken for a serious health condition of a parent, son, or daughter, for the employee's own serious health condition, or a serious injury or illness of a covered servicemember which requires
treatment by a health care provider periodically, rather than for one continuous period of time, and may include leave of periods from an hour or more to several weeks. Examples of intermittent leave would include leave
taken on an occasional basis for medical appointments, or leave taken several days at a time spread over a period of six months, such as for chemotherapy. A pregnant employee may take leave intermittently for prenatal
examinations or for her own condition, such as for periods of severe morning sickness. An example of an employee taking leave on a reduced leave schedule is an employee who is recovering from a serious health condition
and is not strong enough to work a full-time schedule.
(2) Intermittent or reduced schedule leave may be taken for absences where the employee or family member is incapacitated or unable to perform the essential functions of the position because of a chronic serious health
condition or a serious injury or illness of a covered servicemember, even if he or she does not receive treatment by a health care provider.
(c) Birth or placement. When leave is taken after the birth of a healthy child or placement of a healthy child for adoption or foster care, an employee may take leave intermittently or on a reduced leave schedule only if the
employer agrees. Such a schedule reduction might occur, for example, where an employee, with the employer's agreement, works part-time after the birth of a child, or takes leave in several segments. The employer's
agreement is not required, however, for leave during which the mother has a serious health condition in connection with the birth of her child or if the newborn child has a serious health condition.
(d) Qualifying exigency. Leave due to a qualifying exigency may be taken on an intermittent or reduced leave schedule basis.
