Sandhills Community College
Family Medical Leave Request Form
Name: SSN:
Home Address: Home Phone:
(P.O. Box or Street Address)
Work Phone:
(City)
(State / Zip)
Department: Supervisor’s Name:
Date of Employment: Position:
Request is for: (check one) birth, adoption, or foster placement of a child
serious health condition of employee
care for spouse, son, daughter, or parent with a serious health
condition (dependant under age 18; or age 18/older and
incapable of self-caredue to a disability)
serious health condition that renders employee unable to
perform job
qualifying exigency due to employee’s spouse, son/daughter, or
parent who is on active duty or has been notified of an impending call
to active duty status in support of a contingency operation as a
member of the National Guard or Reserves (or as a retired member of
the regular Armed Forces or Reserves). Please complete FORM
WH-384, “Certification of Qualifying Exigency for Military Family
Leave” (in addition to this form).
servicemember family leave as a spouse, son/daughter, parent, next
of kin of a covered servicemember with a serious injury or illness.
Please complete FORM WH-385, “Certification for Serious Injury
or Illness of Covered Servicemember for Military Family Leave” (in
addition to this form).
Note
: If FMLA is requested for non-military care of your spouse, son, daughter, or parent with a serious health
condition, the following information must be provided:
Name of spouse, son, daughter, or parent and explanation of relationship:
Briefly explain reason for leave request:
Date FMLA leave is to begin: Date expected to return to work:
Once the completed Certification Form has been evaluated, another form will be used to
confirm eligibility of leave
.
