FMLA - Request for Information and Notice of Need for Leave Form
Employee Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
What type of leave is needed?
*
Intermittent
Continuous
When do you anticipate FMLA to start?
*
-
Month
-
Day
Year
Date
Reason for Leave
*
Please Select
Your own serious health condition
To care for your child
To care for your spouse
To care for your parent
Birth or adoption of a child
Employee Phone Number
*
Please enter a valid phone number.
Employee Email
*
example@example.com
How would you like the information to be sent to you?
*
Email
Mailed to home address
If you selected mailed above, please provide the best address below (this will not update your address on record with Human Resources):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who will be completing your time record(s) while you are out?
*
Submit
By clicking the “Submit” button, I consent to be contacted via email.
Should be Empty: