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FMLA Leave Request Form

 

COMPANY INFORMATION

Company Name *
Contact Person Name *
Contact Phone *
Contact Email *

EMPLOYEE INFORMATION

Employee Name *
Address *
City *
State *
   Zip *
Employee Email Address (Provide personal and work email addresses) *
Date of Birth * (mm/dd/yyyy)
Date of Hire * (mm/dd/yyyy)
Number of Hours Worked Weekly *
Days Normally Worked *                                    
Total hours worked the previous 12 months                              
 
List any absences under FMLA since the start of the FMLA plan year:
Employee Phone:
Employee Job Title:
  Exempt      Non-Exempt
List Essential Job Duties:
Accommodations: Is employee currently being accommodated under ADAAA? Yes      No
Please List Accommodations:

PURPOSE OF LEAVE

Purpose of Leave (check all that apply) *
Because of the birth of a child and to care for the newly born child, or placement of a child with the employee for adoption or foster care
To care for an immediate family member (spouse, child or employee’s parent) with a serious health condition
Because of the employee’s serious health condition which makes the employee unable to perform the functions of the employee’s job
Recreation or pleasure
Military Family Leave
Other reason:
Type of leave requested for the purpose identified above (check all that apply) *
Paid vacation
Accrued paid medical/sick leave
Unpaid family and medical leave
Other type:
If the leave involves the serious health condition of the employee or immediate family member, does the employee request intermittent leave or leave on a reduced work schedule?
Yes      No
  If “Yes” is checked above, explain why intermittent leave or leave on a reduced work
schedule is necessary, and the schedule for medical treatment:

DATES OF LEAVE AND NOTIFICATION

Anticipated Starting Date of Leave * (mm/dd/yyyy)
Anticipated Date of Return * (mm/dd/yyyy)
Last Day Worked * (mm/dd/yyyy)
Was Employer Notified Previously? * Yes      No
  If notified, enter date of notification (mm/dd/yyyy)
Should CAHS collect employee contribution(s) during this leave? Yes      No
Date through which employee contribution for medical and/or dental coverage has been paid * (mm/dd/yyyy)

Amount of employee contribution(s) for CAHS to collect per pay period*

Frequency of pay periods *
Comments: