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NEO$A&M College - Human$Resources Department
Family Medical Leave Act (FMLA) Request Form
To be completed by employee and/or supervisor, and submitted to the HR Department.#Please no te that FMLA is not approved
simply by completing this#request#form. HR will contact you to complete additional FMLA paperwork no later than#5 days after
receiving this request (29 C.F.R 825 .300 (b )).
Employee Name:________________________________________Employee'ID #:_______________________
Department:___________________________________________Supervisor:___________________________
#1) REASON'FOR'LEAVE
I request a leave of absence from __________________(date) to__________________(date) for the
following'reason:
For birth of my child and/or to care for the newborn child.
For placement of a child with me for adoption or foster care.
To care for my (circle one): spouse, child or parent with a serious health condition.
*Name:__________________________________
Because my own serious#health condition makes me unable to perform one of the essential
functions of my job.
Qualifying exigency#arising out of the fact that my (circle one): spouse, son, daughter,
or parent is a covered service member on active duty (or has been notified of an impending call or order to
active duty) in support of a contingency operation.
I am the (circle one): spouse,#son,#daughter, parent, or next of kin of a covered service#member#with#a
serious#injury or illness, and I am needed to care for this individual.
For another reason. (Please specify)
#2) TYPE'OF'LEAVE REQUESTED: Continuous In te rmittent (inconsistent time) Reduced Schedule
Amount of Time Requested:______________________________' Days Hours' Weeks
Explanation of length and type of leave
requested:_________ ___ ____ ____ ___ ____ ___ ____ ____ ___ ____ ___ ____ ____ ___ ____ ___ ____ ____ ___ ____ ___ ____ ____ ___ ____
I c
an be re a ch e d at the fo llo w in g address and phone during my
leave:__ _ _ _______ _ _ _ _ _ _ _ _ _ _ _______ _ _ _ _ _ _ _ _ _ _ _______ _ _ _ _ _ _ _ _ _ _ _______ _ _ _ _ _ _ _ _ _ _ _______ _ _ _ _ _ _ _ _ _ _____
Signature$of Employee$or Representative$ Date Supervisors Signature$ Date
Received by:___________________________________
Signature$of HR Representative$ Date
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