I - Request for Family & Medical Leave

REQUEST FOR FAMILY AND MEDICAL LEAVE

(In accordance with the Family and Medical Leave Act (with revisions of November 17, 2008) and including the provisions of the National Defense Authorization Act for FY2008.)

Name: ____________________________________________

Type of Leave/Absence:

o The birth of a child and the care of such child;

o The placement of a child for adoption or foster care;

o Serious health condition (as defined by FMLA Act) of an employee’s spouse, child, father, mother;

o Serious health condition (as defined by FMLA Act) that makes the employee unable to perform his or her job functions.

o A qualifying emergency arising out of the fact that an employee’s spouse, child, or parent is on active duty (or has been notified of an impending call or order to active duty in the Armed Forces) in support of a contingency operation.

Certification: I hereby request leave/approved absence from duty as indicated above and certify that such leave/absence is requested for the purpose(s) indicated. I understand that I must comply with my employing agency's procedures for requesting leave/approved absence (and provide additional documentation, including medical certification, if required) and that falsification on this form may be grounds for disciplinary action, including removal.

Employee signature:__________________________ Date:_______________

o Approved

o Disapproved

Reason for disapproval: ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Director Signature:______________________ Date:___________________

Posted online September 7, 2021