Request for Leave of Absence Under The Family and Medical Leave Act of 1993

Employee's First Name

Last Name

Location/Program

Location/Program Address

Location/Program City State Zip

If your location is not listed above, please specify

Reason for Request for Leave of Absence

If care of a family member, which family member?

Please provide a short description for this Leave of Absence request

Requested length of Leave of Absence

From

If you are requesting intermittent leave, please list dates and hours you are requesting. Please also provide the reasons why such a schedule is necessary

If this request for leave of absence is based upon a family member's or your serious health condition, a doctor’s note is required to support your request. In addition you may be required to complete a Certification of Health Care Provider form at HR’s request.

IMPORTANT - READ BEFORE SIGNING:

I understand that my Request for Leave of Absence is governed by the Family and Medical Leave Act of 1993. My rights and obligations under the Act, as well as any consequence occasioned by my failure to comply with these obligations, are detailed in EDSI’s Family and Medical Leave Act of 1993 Policy, which I have read and understand. I also understand that a Leave of Absence is unpaid. PTO does not accrue and I am responsible for paying my benefits premiums to EDSI during this leave.

Date

Full Name