FMLA

Name

First Name

Last Name

Employee ID Number

Is the FMLA request for yourself or a family member?

Self

Family Member (Parent, Child, or Spouse)

Type of Leave Requested

Intermittent Leave (as needed, up to 3 consecutive days)

Full-Time Leave (block leave for an extended period)

Start Date

Your Classification and Division

Personal Email

County Email

While your leave request is being processed, please indicate which leave bank(s) you wish to utilize:

Sick

Vacation

Please Review the FMLA Policy and Sign to confirm that you have read the policy

Signature

I confirm that I have Read The FMLA Policy

Todays Date

Date

FMLA Policy Review

Please Review the FMLA Policy and Sign to confirm that you have read the policy