Eligible employees are entitled under the Family and Medical Leave Act (FMLA) for up to 12 weeks of job-protected leave for certain family and medical reasons. Submit this request form at least 30 days before the leave is to commence. When submission of the request 30 days in advance is not feasible, submit the request as early as possible. The university 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.

Required items

Employee Information






General Information Yes No
Yes No
FMLA Leave Request Information

I request leave for the following reason:

Birth of a child
Placement of a child after adoption or for foster care
Personal serious health condition
Serious health condition of immediate family member
Qualifying military exigency of an immediate family member
To care for a covered servicemember with a serious injury or illness


Time off work is expected to be (select the most appropriate box):

For a continuous block of time (several continuous days, weeks, or months off work)
On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week;
       examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatment/appointments)
For a reduced work schedule (change in work schedule needed-fewer hours per day or fewer hours per week)

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Report of Signature

By signing below, I certify that I have read and agree with the statements listed above.

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