4-15: Request for Medical Leave Form

Employee Name:  ____________________________  Department: _______________________


Address: ___________________________________   Phone number: _____________________


City: __________________________ State: _______  Zip Code: _________________________


Employee’s Title:  ____________________________ Work Schedule: ____________________


Supervisor’s Name/Title:  ________________________________________________________


*Patient’s Name/Relationship to employee: __________________________________________


Date of Request:  ____________________ Employee’s Hire Date:  _______________________


Date Requested Leave to Begin: _____________ Proposed Return Date to Work: ____________


Type of leave to be used while on FMLA:

() Annual        () Sick     () LWOP (leave without pay)     () Donated Leave     () Intermittent use


Reason for Leave:

()         Birth of a child or the placement of a child for adoption or foster care.

()         A serious health condition of the employee that prevent you from performing the essential functions of your job.

()         A serious health condition affecting your *spouse/domestic partner, son or daughter, or parent for whom you need to provide care.

()         Because of a qualifying exigency arising out of the fact that your spouse, son, daughter or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.

()         Because you are the spouse, son, daughter or parent next of kin of covered service member with a serious injury or illness.

NOTE:  A family medical leave request based on an employee’s serious health condition or the serious health condition of an employee’s spouse, child, or parent must be accompanied by a “Medical Certification Statement”.  Policy 4-15 is attached.


I authorize Santa Fe Community College to contact my physician to verify the reason for my leave request or for any other information concerning my family medical leave.


I understand that if I fail to return to work at the end of my requested leave, it will be treated as a resignation unless an extension has been granted and approved in writing by Santa Fe Community College.


Employee’s Signature:  _________________________________   Date:  __________________


Immediate Supervisor:  _________________________________   Date:  __________________


Dean Signature:  ______________________________________    Date:  __________________


Executive Director for Human Resources:  ___________________            Date:  __________________