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REQUEST FOR FAMILY AND MEDICAL LEAVE
TO BE COMPLETED BY THE EMPLOYEE OR SUPERVISOR
Name(Last, first, middle)
Employee ID
Department
Date of Request
Supervisor’s Name
I request family and medical leave for:
Birth/Adoption/Foster care
Serious health condition of spouse, parent, son, or daughter
(son or daughter must be under 18 or 18 and disabled).
Serious health condition of self.
Qualifying exigency arising out of the fact that my spouse, son, 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.
Serious injury or illness of spouse, son, daughter, parent or next of kin of a covered service member.
I request to be out: Begin date __________ End Date __________
Block time
Reduced Load
Intermittent
Is your spouse employed by EPCC?
Yes____
If yes, name of spouse ___________________________.
No____
Note: If your spouse is also employed by El Paso Community College, both you and your spouse are limited to
12 work weeks COMBINED if your leave request is for:
‚ Birth/Adoption/Foster Care
‚ Serious health condition of spouse, son, daughter, or parent
‚ Qualifying exigency
And 26 work weeks COMBINED if your leave request is for a serious injury or illness of spouse, son,
daughter, parent or next of kin of a covered service member.
Once we receive your request, we will inform you whether you meet the eligibility requirements for FMLA.
_____________________________
Signature of Employee or Supervisor
FORWARD COMPLETED FORM TO EMPLOYEE BENEFITS,
ASC, BLDG. A, ROOM 129, FAX # 831-6518