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

An eligible, full-time employee may be granted up to a maximum of 12 weeks of unpaid FMLA leave in a 12-month period of time for any one of the following reasons:

  • To care for the employee’s spouse, children or parent with a serious health condition
  • Because of a serious health condition that makes the employee unable to perform the functions of his/her job
  • For the birth of the employee's child, and to care for the newborn child 
  • For the placement with the employee of a child for adoption or foster care

An employee will not accrue PTO during this leave of absence.

A full-time employee is eligible for FMLA after one year of employment.

Please complete this form to request a Leave of Absence. Please fill out completely in advance of the leave, where possible. Check the Employee Handbook for any applicable deadlines and more details on the process.

Requested length of Leave of Absence


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