Fillable FMLA Request Form 3-9-16 (City University of New York)

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FMLA Request Form 3-9-16 (City University of New York)

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Eligible employees are entitled to up to 12 weeks of unpaid job-protected leave for certain family and medical reasons.
If you wish to request FMLA leave, this form must be submitted as early as practicable, preferably no fewer than 30 days in advance of the start
of your leave. CUNY reserves the right to deny or postpone leave for failure to give appropriate notice.
FAMILY AND MEDICAL LEAVE ACT (FMLA) - REQUEST FORM
Name
Date
OHRM - FMLA REQUEST FORM - 2015
RECEIVED BY (This form must be signed by the Director of Human Resources or Designee)
Contract Title
Empl. ID
Name
Employee Information:
Date
EMPLOYEE STATEMENT OF UNDERSTANDING
Reason for requesting leave (Check appropriate box)
My own serious health condition (Attach Certification of Healthcare Provider)
Birth of my child; to care for my newborn child
Family member is on or has been called to active duty in the military (Attach Certification of Qualifying Exigency & Certification of Family Relationship Form)
Placement of child with me for adoption or foster care
To care for my family member with serious health condition (Attach Certification of Healthcare Provider & Certification of Family Relationship Form)
Date of birth
Attach appropriate documents
Date of placement
Period of Leave
I request CONTINUOUS FMLA LEAVE, starting
Date
and ending
Date
Date
I request INTERMITTENT FMLA LEAVE, starting
Date
and ending
Date
I request REDUCED WORK SCHEDULE FMLA LEAVE,
starting
Number of hours/week
Anticipated schedule of absence must be discussed with supervisor.
For Intermittent or Reduced Work Schedule, appropriate documents must be attached.
I am aware of and understand the following:
1. If the leave is for my own serious health condition or to care for a family member with a serious health condition, I must return a completed
medical certification form to the Office of Human Resources within 15 days of the College's request, or as soon as practicable. Failure to do
so may result in my leave being delayed until I provide this documentation; if the certification is not clear, the College can contact the
Healthcare Provider for clarification.
2. Following a leave for my own serious illness, I may be required to present a fitness for duty certification to the Office of Human Resources.
3. My health benefits will continue during my leave and I am expected to continue to pay my share of health insurance premiums, if any.
4. If, under current University leave policies, I am eligible to lengthen this leave or request other leave benefits, I will submit the appropriate
documents to the Office of Human Resources, prior to the conclusion of my FMLA leave.
5. If I fail to return to work upon the conclusion of this approved leave, I may be subject to disciplinary proceedings or other action in
accordance with CUNY policies and applicable collective bargaining agreements.
Contact information while on leave
Home Phone
Email
Cell Phone
Supervisor Name
Phone
Email
To care for a seriously injured or ill servicemember or veteran related to employee (Attach Certification of Healthcare Provider & Certification of Family
Relationship Form)
FMLA FORM 1
Signature
Signature
College
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FMLA Request Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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