Medical Leave Request Form
(Illness/Injury for self, family member or service member)
Wichita State University * Office of Human Resources *
Wichita, KS 67260-0015
Phone: (316) 978-3065 * Fax: (316) 978-3201
(Rev. 9/2017)
Name: myWSU ID#
Home Address:
(City) (State) (Zip Code)
Home Telephone: Work Telephone:
Department Name: Campus Box Number:
Supervisor’s Name:
Is this a work related injury/illness? Yes No
Request is for:
Self Care for Family Member
Relationship of family member:
To Care for
a Covered Service Member
For Qualifyi
ng Exigency for Military Family Leave
Dates of Medical Leave Beginning: End:
Briefly Explain Health Condition Requiring Leave (Self or Family Member or Service Member):
Type of Leave Requested: Full-Time Part-Time Intermittent
If you will go into an unpaid status during your leave and you want to avoid discontinuing your health insurance,
indicate how you want to pay your share of the insurance premium:
Prepayment by payroll deduction;
Prepayment by personal check (overpayments will be refunded); or
Payment by personal check – Bi-Weekly
Does Not Apply
I certify that the information contained on this form is correct to the best of my knowledge. I authorize Human
Resources to obtain and verify any necessary information regarding my request for medical leave. I understand that
providing incomplete or false information may result in disqualification of my leave request and/or disciplinary
actions up to, and including, termination of employment.
Employee Signature Date
Return to: Human Resources via Email: totalrewards@wichita.edu; Fax: 316-978-3201; or
Mail: Leave Administrator, Campus Box 15
