FMLA Employee Requests Page

Employee Name

Employee Email (for confirmation of this request)

Requested Start Date:

Estimated End Date:

The reason for this FMLA leave request is (select the most appropriate box):

Birth of a son or daughter and to care for the newborn child.

Placement with the employee of a son or daughter for adoption or foster care.Choice

To care for the employee’s spouse, son, daughter or parent with a serious health condition.

A serious health condition that makes the employee unable to perform the functions of the employee’s job.

A qualifying exigency arising out of the fact that the employee’s spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status).

To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered servicemember.

To care for the employee’s child when the employee is unable to work (or telework) due to the closing of the child’s school, place of care, or unavailability of the regular childcare provider due to a public health emergency with respect to COVID-19.

UntitledTime off work is expected to be (select the most appropriate box):

For a continuous block of time (several continuous days, weeks or months off work).

For a reduced work schedule (change in work schedule needed—fewer hours per day or fewer hours per week).

On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week; examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatment/appointments).

Employee Signature

Date

FMLA Employee Request Form