FMLA & Military Leave Request Form
Full Legal Name
*
First Name
Last Name
CPR Email Address
*
example@example.com
What was your hire date?
*
-
Month
-
Day
Year
Date
Are you full-time or part-time?
*
Full-time benefit eligible (35+ hours)
Part-time benefit eligible (30-34 hours)
Part-time not benefit eligible (29 hours or less)
What is your expected FMLA start date?
*
-
Month
-
Day
Year
Date
Why are you going out on leave?
*
Please Select
Birth of child or placement of child for adoption / foster care
Your own serious health condition
You need to care for your family member due to a serious health condition
Qualifying exigency (family military active duty)
Need to care for military servicemember
Military
What is the type of FMLA leave you intend to use?
*
Please Select
Intermittent
Continuous
Reduced Work Schedule
TBD - Unknown
Military
Please provide a copy of your current military orders.
*
Browse Files
Drag and drop files here
Choose a file
This is required to submit your FMLA for approval.
Cancel
of
Do you have PTO?
*
Yes
No
How many hours?
*
Your FMLA submission is confidential. The health information included will not be viewed by anyone other than HR; however, your supervisor will be notified of the leave request.
Supervisor's Full Legal Name
*
First Name
Last Name
Supervisor's CPR Email
*
example@example.com
Submit
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