Important information regarding your request
To receive a Family Medical Leave Act (FMLA) information packet and full application, please complete the following form. Human Resource Services will notify you within five business days of the receipt of this form of your eligibility
for FMLA. At that time, an information packet and the necessary forms will be provided.
Upon receipt of this form, Human Resource Services will notify your supervisor of your request for leave, including
your general reason for leave, if the leave is for yourself or a family member, your type of leave (continuous or intermittent), and the estimated dates of
your leave as you indicate below. Specific medical conditions/information will not be shared.
Employees must follow their departmental call-in procedures for any absences until their requests for leave has been received, reviewed, and approved.
A notification will be sent to the employee and their supervisor upon approval of the leave request.