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
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.

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