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: __________________