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:

Report of Signature

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

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