EmailMe Form - EMPLOYEE FMLA REQUEST FORM

Name *

First Last

Phone Number: *

### - ### - ####

E-Mail Address: *

Requested FMLA Start Date *

MM / DD / YYYY

Requested FMLA End Date *

MM / DD / YYYY

The reason for this FMLA leave request is (select the most appropriate box): *

1) Birth of a son or daughter and to care for the newborn child.

2) Placement with the employee of a son or daughter for adoption or foster care.

3) A serious health condition that makes the employee unable to perform the functions of the employee's job.

4) A qualifying exigency arising out of the fact that the employee's spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status).

5) To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered servicemember.

6) To care for the employee’s child when the employee is unable to work (or telework) due to the closing of the child’s school, place of care, or regular childcare provider is unavailable due to a public health emergency with respect to COVID-19.

Child's Name *

First Last

Child's Birth Date *

MM / DD / YYYY

Please provide the name of the school, place of care, or child care provider that has closed or become unavailable. *

If the child listed above is over the age of 14, please provide a statement that indicates why this child needs care during daylight hours. *

By checking 'Yes' below I affirm that no other suitable person will be providing care for the child/children listed above during the period for which I am requesting paid sick leave or expanded family and medical leave. *

Yes

No

Time off work is expected to be (select the appropriate box): *

1) For a continuous block of time (several continuous days, weeks or months off work). Dates indicated above.

2) For a reduced work schedule (change in work schedule needed—fewer hours per day or fewer hours per week). Indicate requested schedule below.

3) On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week; examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatment/appointments).

Requested Reduced Work Schedule

	Start	End
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please provide any additional information that will help process this request.

Please attach any documents that will help process this request.