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Request for Family and Medical Leave Act (FMLA) Leave
Name: _______________________
_____________________
Last
______
First
Phone #: ______________________
MI
University ID: __________________
Address During Leave: ____________________________
Street
_________________
City
_______
State
___________
Zip
Requesting Leave For:
The birth of a child, or placement of a child with you for adoption or foster care.
Please indicate, care for your ____ spouse; ____child; or ____ parent due to his/her serious health
condition.*
My own serious health condition.*
Please indicate, qualifying exigency arising out of the fact that your ____ spouse; ____ son or daughter; or
____ parent is on active duty or call to active duty status in support of a contingency operation as a member
of the National Guard or Reserves.*
Please indicate, you are the ____ spouse; ____ son or daughter; ____ parent; ____ next of kin of a covered
service-member with a serious injury or illness.* (Maximum of 26 weeks)
Requesting Leave From: _________________________ To: _______________________
(Maximum of 12 weeks, except for care of a Service Member)
Leave to be Taken On:
Continuous Basis
Intermittent Basis (units of days or hours at a time)
Reduced Schedule (reduction in hours/day or days/week)
Leave To Be:
Paid, using Accrued Sick Leave (for your own illness only)
Paid, using Family Caregiving Leave (limited to available accrued leave)
Paid, using Accrued Vacation
Paid, using Accrued Compensatory Time Off
Unpaid
Employee Signature: __________________________________________
Date: ____________________
Supervisor Signature: _________________________________________
Date: ____________________
A supervisor signing this form is only acknowledging request for leave. Official FMLA qualification and approval is handled through Human Resource
Services.
For additional information please contact HRS, or visit www.uni.edu/hrs/benefits/fmla/
* Requires corresponding “Certification” form which is available in the Human Resource Department.
Employee should complete this form and submit it to his/her supervisor. The department should forward the signed form
to the Human Resource Services Office, 027 Gilchrist, 0034.
Revised 11/2012
BENEFITS
027 Gilchrist  Cedar Falls, IA 50614-0034  Phone: 319-273-2422  Fax: 319-273-2927  http://www.uni.edu/hrs