EMPLOYEE REQUEST FOR FAMILY OR MEDICAL LEAVE (FMLA)

Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to 12 weeks (13 weeks in any 2 calendar years under RI Family Leave Act) of job-protected leave for certain family and medical reasons. Twenty-six workweeks of leave during a single 12-month period is available to care for a covered service member with a serious injury or illness if the eligible employee is the service member’s spouse, son, daughter, parent, or next of kin.

Employee must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and must comply with the normal call-in procedures.

EMPLOYEE INFORMATION

Today’s Date: ___/___/___ Hire Date :___/___/___

Employee Name:________________________________________________________________

Employee Home Address:_________________________________________________________

Work Location:_________________________________________________________________

Home Phone Number:_________________Cell:___________________________________

REASON FOR REQUESTING LEAVE

☐ My own serious health condition

☐ Birth of my child, to care for my newborn child

☐ Placement of a child with me for adoption or foster care

☐ Leave to care for a family member with a serious health condition

Relationship of family member to you_________________________

☐ Qualifying exigency because a family member is on or has been called to Active duty in the Armed Forces (including the National Guard or Reserves)

Relationship of family member to you_________________________

☐ Leave to care for a family member who is a member of the Armed Forces or covered veteran and who is undergoing medical treatment, recuperation, or therapy for a serious injury or illness

Relationship of family member to you__________________________

DURATION OF LEAVE

Leave expected to begin___/___/___ Leave expected to end ___/___/___

EMPLOYEE CERTIFICATION AND SIGNATURE

I certify that the above information is true and correct to the best of my knowledge:

Employee Signature________________________________________________ Date ___/___/____