Request for Family Medical Leave (FML)
Employee’s Name__________________________________ Date Requested__________
My date of hire_____________
My department and job title________________________________________________
My work location is ______________________________________
I □ have □ have not taken a leave of absence in the past twelve (12) months.
I □ have □ have not worked at least 1250 hours during the last twelve (12) month
period immediately preceding my request for leave or the date on which the leave
commences, whichever comes first.
I request a leave of absence for the following reason:
□ To care for my child who was born on: ________________
□ Because I am adopting a child who will be placed with me on: _____________
□ Because a child is being place with me for foster care beginning on:_________
□ To care for my spouse, child, or parent who has a serious health condition that
began on: ______________
□ Because of a serious health condition that began on ______________ and that
renders me unable to perform the functions of my job.
I would like the leave to begin:___________________
I expect to return to work on: ____________________
My address and telephone number during the leave will be:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
________________________________________
Employee’s Signature
An eligible employee, upon request, may be granted up to twelve (12) work weeks of unpaid FML during
any consecutive twelve (12) month period of employment.
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signature
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