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FMLA Leave Request

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Family and Medical Leave Request

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
Pick a date to Pick a date
Report of Signature
I acknowledge that if my FMLA request is approved, I am responsible to report to work on the date agreed upon. If there are circumstances that change and will not allow me to return to work on that date, I agree to inform my supervisor and Human Resources.
I understand my benefits will continue during my leave; however, I must arrange to pay my share of applicable premiums.
I acknowledge that I have read Policy 1308-Family and Medical Leave.

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