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2. Employee FMLA Request Form

   Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to 12 or 26 weeks of job-protected leave for certain family and medical reasons. Submit this request form to your human resources manager at least 30 days before the leave is to begin, when possible. When 30 days’ advance submission of the request form is not possible, submit the request as soon as possible. The City reserves the right to deny or postpone leave if you do not give adequate notice when permitted under federal and/or state law.

6. Employee Information
8. First Name
9. Last Name
11. Employee ID#
12. Department
13. Job Title
15. Today's Date
    Today's Date
16. Hire Date
    Hire Date
17. Supervisor
19. Employment Status

    1. Full-Time

    1. Part-Time

    1. Temporary
23. Reason for Requesting Leave
25. Check all that apply

    I am requesting family/medical leave for the following reasons:

    1. Birth of my child; to care for my newborn child
    2. Placement of a child with me for adoption
    3. Placement of a child with me for foster care
    4. Leave to care for a family member with a serious health condition
    5. My own serious health condition
    6. Qualifying exigency because a family member is on or has been called to covered active duty in the Regular Armed Forces (including the Nation Guard and Reserves) to a foreign country
    7. Leave to care for a family member who is a current member of the Armed Forces or a covered veteran and who is undergoing medical treatment, recuperation, or therapy, is in an outpatient status
    8. Leave to care for a family member who is a current member of the Armed Forces or a covered veteran and who is on a temporary disability retired list for a serious injury or illness
    9. Other (please explain below)
27. Additional Information

    Please list family relationship for any check boxes above or for a selection of "other".

31. Duration of Leave
33. Expected start and end date of leave
    Expected start and end date of leave Start Date

    —

    Expected start and end date of leave End Date
35. Additional Information

    If intermittent or reduced-leave schedule is being requested, please explain why it is needed and the proposed leave schedule.

39. Employee Certification and Signature

    I certify that the above information is true and correct to the best of my knowledge.

41. Employee Signature*

    Please type your name.  This will be used as your signature authority for this form.

42. Today's Date*
    Today's Date
44. EMPLOYER: This form should be treated as a medical record and must be maintained separately from employee personnel files, in locked cabinets with only designated personnel having access. As an employer, you should retain this original and provide a photocopy of the form to your employee along with the City Response form within a reasonable period of time.
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field