University of Oklahoma
Receipt of FMLA Information Certification
This original document is to be returned to the Office of Human Resources / Employee Relations - NEL
259 - Norman, Oklahoma 73019. If you have questions, please contact Employee Relations at 325-3706.
I have received the following information (Check all that applies):
The Employee Rights, Responsibilities and Guidelines document
Certification by Health Care Provider Form
Employee Request for Medical Leave and FMLA
Request for Adoption / Placement Leave and FMLA
Request for Military Leave for care of a family member
I also understand that I may obtain this information from the Office of Human Resources' Web site at any
time. Address: hr.ou.edu/employee resources
Print Recipient’s Name Here (please write legibly)
EMPLID Here
Recipient’s Signature
Date
Name of person providing the Information
EMPLID Here
Department Name
Phone Number
Signature of Person Providing the Information
Date
NOTIFICATION: Provide all names of individuals within the employee’s department who should receive
notice of the employee’s approval or denial of FMLA provided by the Office of Human Resources. Questions
may be directed to Employee Relations and Development 325-3706.
Department HR Representative:
Phone Number:
Immediate Supervisor:
Phone Number:
Dean/Director:
Other: