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:  __________________

AUTHORIZATIONS:

Immediate Supervisor:  _________________________________   Date:  __________________

 

Dean Signature:  ______________________________________    Date:  __________________

 

Executive Director for Human Resources:  ___________________            Date:  __________________

Irrigation Repair

Santa Fe Community College will be repairing irrigation lines at the central roundabout (the drop-off area by the flag poles) Monday, April 23 through Monday, April 30. During repairs, the roundabout will not be accessible. Please use other entrances into the main and West Wing parking lots. No parking areas will be affected. Please use caution when walking or driving in the vicinity. Thank you for your patience while we make improvements to campus.