FMLA Request

The Family and Medical Leave Act (FMLA) is a federal regulation that grants Eligible Employees the right to take up to 12 workweeks of job-protected leave over a 12-month period for FMLA covered medical and family reasons. An employee is eligible for up to 26 workweeks of leave in a Single 12-Month Period to care for a Covered Service member, limited to a combined total of 26 workweeks for all types of FMLA leave.

Name	*
Employee ID	*
Department	*
Supervisor	*
Mailing Address	*
FMLA Start Date
FMLA End Date
Leave requested for the following purpose:	The birth of my child, or the placement of a child with me for adoption or foster care. My serious health condition. A serious health condition affecting my spouse, child, or parent for which I am needed to provide care. I am the spouse, child, or parent of service member with a serious injury or illness. A qualifying exigency arising out of the fact that my spouse, child, or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.
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