To be completed by employee:
Employee name
Job title
Human Resources
Family and Medical Leave Request
Social Security Number
Supervisor or Dept. Head
Clear form
Date
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to up to 12 weeks of job-protected leave for
certain family and medical reasons. Submit this request form to your supervisor or department head at least 30 days before the
leave is to commence, when possible. When submission of the request 30 days in advance is not possible, submit the request as
early as is possible. The employer reserves the right to deny or postpone leave for failure to give appropriate notice when such
denial/postponement would be permitted under federal or state law.
Yes Counting any periods of time you worked for the University System of Georgia, University System office (whether they were consecutive or
1.
not), have you
worked for a total of 12 months or more? (If “yes,” continue to question 2. If “no,,” stop here.
2.
3.
No
Yes
No
Yes
No
Sign and submit this form to your supervisor or department head.)
During the past 12 months, have you worked at least 1,250 hours (approximately eight months of 40-hour weeks or one
year of 25-hour weeks)? (If “yes,” continue to question 3. If “no,” stop here. Sign and submit this form to your supervisor
or department head.)
Have you previously received medical or family leave?
If yes, provide information below:
Dates of leave _______________ to _______________
Purpose of leave
4.
5.
Yes Have you taken any intermittent medical leave?
No
Yes Have you taken time off from scheduled hours?
If “yes,” provide details
No
6 Yes Is your spouse employed by the University System of Georgia, University System Office?
No
If “yes,” spouse’s name:
Reasons for requesting leave
Leave must be granted for any of the following reasons:
• For a serious health condition that prevents you from performing the duties of your job;
• To care for your child, spouse, or parent who has a serious health condition; or
• To care for your child after birth, or for placement after adoption or foster care.
I request leave for the following reason:
Personal serious health condition
Serious health condition of:
Birth of a child
spouse child parent
Adoption or placement of a child for foster care
Scheduled date of adoption or placement
