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Employee FMLA Request Form

  1. 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.

  2. Employee Information
  3. Employment Status
  4. Reason for Requesting Leave
  5. Check all that apply

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

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

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

  9. Employee Certification and Signature

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

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

  11. 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.
  12. Leave This Blank:

  13. This field is not part of the form submission.