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Claflin Fmla Request Form

The document is a leave of absence request form for an employee. It requests information about the employee, the reason for leave, the requested leave dates, and requires approval signatures from supervisors. It also has sections for faculty to provide information about any classes or office hours that will be missed during the leave period.

Uploaded by

Az Corker
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
47 views

Claflin Fmla Request Form

The document is a leave of absence request form for an employee. It requests information about the employee, the reason for leave, the requested leave dates, and requires approval signatures from supervisors. It also has sections for faculty to provide information about any classes or office hours that will be missed during the leave period.

Uploaded by

Az Corker
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Request for Leave Application

Leave of Absence & FMLA

To be completed by employee requesting leave:

Employee Name: _______________________ ID#___________________(For HR Use Only)


Date of Hire: _______________________ Employee Status: Faculty ___ Staff ____ Adm. ____
Department: _______________________ Division: ____________________________________
Work Schedule: _______________________ (For faculty only, complete back of form)
Reason for leave request:
___ *Care for a newborn or adopted child ___ Illness of employee
___ *Serious health condition (employee) ___ Vacation - Days available _______
___ *Care for spouse, child or parent with a ___ Funeral
serious health condition ___ Military Leave (copy of orders required)
(*Applicable to FMLA) ___ Other: Please identify ___________
___ Official Business: State nature of business, indicate the University official who authorized or is sending
you on this leave_____________________________________________________________________
If University resources are required for travel, must complete and attach an approved copy of the Travel Request Form.

Requested leave schedule (please check one):


___ Consecutive Days
____ Intermittent Schedule (provide details) ____________________________________________________
Date leave is to begin: Date _______________ Day _________________ Hour ___________ a.m./p.m.
Expected return: Date _______________ Day _________________ Hour ___________ a.m./p.m.
Number of weeks/days: ________________
In case of an emergency, where can you be reached? _______________________________________________
Have you taken a Family and Medical Leave of Absence, or a Leave of Absence prior to this request?
____ Yes ____ No If yes, please indicate date and duration of prior leave ______________________
Employee’s signature: ___________________________________________ Date ______________________

Human Resources Certification


Employee is eligible for leave under the Family and Medical Leave Act of 1993 ____ Yes ____ No
Approval/denial letter sent ___________________ (Date)
HR Director’s Signature: ______________________________________ Date: ___________________________
__________________________________________________________________________________________________
Required approvals:
Dept. Chair /Immediate Supervisor’s sign./Date: _________________________Approved ___ Disapproved ___
Dean’s sign/Date: _________________________________________________Approved ___ Disapproved ___
Vice President’s sign./Date: ________________________________________ Approved ___ Disapproved ___
President’s sign./Date: _____________________________________________Approved ___Disapproved ___
(President’s signature is required for 10 or more days)
(Revised, November 2005)
Are you scheduled to have a class during this period? Yes: ( ) No: ( )

CLASS ABSENCES
Dept. No. Title Sect. Hour Bldg/Rm Days Sub. Teachers

Are you scheduled to have office hours during this period? Yes: ( ) No: ( )

OFFICE HOUR ABSENCES


DAYS HOUR

NOTE: THIS REQUEST MUST BE SUBMITTED FORTY-EIGHT (48) HOURS PRIOR TO EFFECTIVE TIME OF YOUR DEPARTURE

Dept: _______ No. _____ Desc. Title: ________________________ Date: __________ Period _________ Bldg/Rm________
ASSIGNMENT ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
REMARKS ______________________________________________________________________________________________________
TEACHER ______________________________________________________________________________________________________

Dept: _______ No. _____ Desc. Title: ________________________ Date: __________ Period _________ Bldg/Rm_______

ASSIGNMENT ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
REMARKS ______________________________________________________________________________________________________
TEACHER ______________________________________________________________________________________________________

Dept: _______ No. _____ Desc. Title: ________________________ Date: __________ Period _________ Bldg/Rm_______

ASSIGNMENT ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
REMARKS ______________________________________________________________________________________________________
TEACHER ______________________________________________________________________________________________________

Dept: _______ No. _____ Desc. Title: ________________________ Date: __________ Period _________ Bldg/Rm_______
ASSIGNMENT ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
REMARKS ______________________________________________________________________________________________________
TEACHER ______________________________________________________________________________________________________

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