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FMLA LEAVE REQUEST FORM To be completed by employee and×or supervisor, and submitted to the unit human resource contact Employee PCN Class Title Department×Unit×Section Supervisor Date of Hire

How to fill out fmla leave request form

How to fill out the FMLA leave request form:

1. Start by carefully reviewing the form and ensuring that you understand the sections and instructions provided.
2. Begin filling out the form by providing your personal information, such as your name, employee identification number, and contact details.
3. Next, indicate the start and end dates of your requested FMLA leave. Be as specific as possible to avoid any confusion.
4. In the following section, explain the reason for your leave request. Be honest and provide as much detail as necessary.
5. If you have any supporting documentation, such as medical records or a doctor's note, attach them to the form or mention them in the appropriate section.
6. Proceed to complete the certification section of the form. This may require obtaining a healthcare provider's signature or providing additional documentation.
7. Finally, review the completed form to ensure accuracy and make sure all the required sections are filled out. Sign and date the form before submitting it to the appropriate department or individual in your workplace.
8. After submitting the form, periodically follow up with the designated person to ensure that your request is being processed and to address any further steps or documentation required.

Who needs the FMLA leave request form?

1. Employees who require a leave of absence from work due to their own serious health condition.
2. Employees who need time off to care for a family member with a serious health condition.
3. Individuals who are expecting a child, either through birth, adoption, or foster care placement, and need time off work to bond with and care for the child.
4. Employees who have a qualifying exigency arising from a family member's military service.
5. Family members of military service members who require time off to care for an injured or ill service member.
6. Individuals seeking time off work to address issues related to domestic violence, sexual assault, or stalking.

It is important to note that the specific eligibility requirements and procedures for requesting FMLA leave may vary depending on your employer and the applicable laws of your country or region.

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