Create a Website Account - Manage notification subscriptions, save form progress and more.
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.
I am requesting family/medical leave for the following reasons:
Please list family relationship for any check boxes above or for a selection of "other".
If intermittent or reduced-leave schedule is being requested, please explain why it is needed and the proposed leave schedule.
I certify that the above information is true and correct to the best of my knowledge.
Please type your name. This will be used as your signature authority for this form.
This field is not part of the form submission.
* indicates a required field