2020-2021 FMLA Request for Leave

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First Name *

First name of the employee who needs leave

Last Name *

Last name of the employee who needs leave

Phone Number

xxx-xxx-xxxx

Email Address *

Employee ID #

Position *

Your job title

Campus or Department *

Circumstances that Qualify for FMLA Leave

1. Maternity/Paternity/Bonding - The birth of a son or daughter or placement of a son or daughter with the employee for adoption or foster care, and to bond with the newborn or newly-placed child.

2. Family Illness - To care for a spouse, son, daughter, or parent who has a serious health condition.

3. Personal Illness - For your own serious health condition that makes you unable to perform the essential functions of your job. A serious health condition includes incapacity due to pregnancy and for prenatal medical care.

4. Military Duty - For any qualifying exigency arising out of the fact that a spouse, son, daughter, or parent is a military member on covered active duty or call to covered active duty status.

5. Service Member Illness - To care for a covered service member with a serious injury or illness when the employee is the spouse, son, daughter, parent, or next of kin of the service member.

Qualifying Event *

Please Choose the Reason for Your Leave Request

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