Fillable Fmla Documentation 4-5-days Off (Southern Utah University)

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Fmla Documentation 4-5-days Off (Southern Utah University)

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FAMILY AND MEDICAL LEAVE
AUTHORIZATION FORM – 4 to 5 days off
Employees who have worked for at least 1,250 hours during the 12-month period immediately prior to
this request for FMLA leave are eligible for FMLA leave.
Name _____________________________________________ T-Number _________________________
Department ________________________________________ Hire Date __________________________
TYPE OF LEAVE REQUESTED
Check one box:
[ ] Employee Family and Medical Leave
[ ] Extension of previously taken Employee Family and Medical Leave
Previous days taken were ___________________________
[ ] Leave to care for newborn or adopted or child place (via state procedure) for foster care
The Leave will begin on __________________________ and end on _____________________________
Reason for Leave (list any medical conditions, etc, relating to the absence):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
REASON FOR LEAVE
I request family and medical leave for the following reason (check one box):
[ ] My personal serious health condition
[ ] Serious health condition of my child
[ ] Serious health condition of my parent
[ ] Serious health condition of my spouse
[ ] Birth of my child
[ ] Adoption of a child by me or placement of a child with me for foster care
[ ] Servicemember leave for a “qualifying exigency”
[ ] Servicemember leave to care for a family member injured in the line of military duty
I understand that this time off will be recorded as FMLA time off and count towards said time off for the
current year.
_____________________________________________
Employee Signature
_____________________________________________
Date
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Fmla Documentation 4-5-days Off (Southern Utah University)

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Completed 24 July 2020

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