Department Of Health And Human Services Family Medical Leave/family Illness Leave Request Form
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Department of Health and Human Services
Family Medical Leave/Family Illness Leave Request
DHR-ESB3014
DHR-ESB3014
05/09
SECTION A: EMPLOYEE INFORMATION
Employee Name
_________
Date Employed
Address
_________
Telephone Number
________
_________
Beacon ID #
___________________
Work Unit
_________
Classification
________
Request for Family Medical Leave is for:
Request for Family Illness Leave is for:
___Birth and care of child
_____Illness of Spouse
(employee may choose to take vacation and/or sick leave, or any portion
of each, or leave without pay, except that sick leave may be used only for the period of disability
___Adoption of a child
(a maximum of 30 days sick leave, available vacation leave or any portion, or
_____Illness of Parent
leave without pay)
___
Care for child, spouse, or parent due to serious health condition
_____Illness of Child
(employee may choose to exhaust sick and/or vacation leave or any portion of each, or leave without pay)
___Serious health condition
(employee must exhaust available sick leave and may choose to take
vacation, or any portion, before going on leave without pay)
___Qualifying exigency leave for families of covered members
employee may choose to vacation/bonus leave, or any portion, or go on LWOP when necessitated by one of the
qualifying exigency reasons)
Military Caregiver Leave or Covered Service Leave
_____
(employee may choose to exhaust sick leave and/or vacation leave or any portion of leave, or leave without pay to
care for an injured family member)
Leave to Begin:
_ _
Leave to End:__________
Leave Requested: ____Continuous____Intermittent
Total Amount of Leave: Sick _______
Vacation ________
Bonus ________
Type Insurance Coverage:
_______Employee
_______ Employee/Child(ren)
_______ Employee/Family
I am attaching the Health Care Provider Certificate with this request:
____Yes
____No
Note: A copy of the “Certification of Health Care Provider”, “Certification for Serious Injury or Illness of Covered
Service member” for Military Family Leave or “Certification of Qualifying Exigency” for Military Family Leave
form must be completed and attached to this request for processing.
I understand that if I have not included the Healthcare Provider Certification with this request, I will have 15
calendar days to provide a completed Healthcare Provider Certification. I further understand that failure to do so
may result in denial of my request and may adversely affect my employment.
Employee’s Signature
Date
Supervisor’s Signature
Date
SECTION B: DEPARTMENTAL ACKNOWLEDGEMENT
Date Request Received:______________
Date 12 Month Period Begins (Family Medical Leave):
____________ Ends
_______
_
Date 5 Year Entitlement Begins (Family Illness Leave):______________ Ends ________________
Amount of Leave Used (Hours): ________Sick__________Vacation__________Bonus_________LWOP(No Leave)
Total Number of Hours Out:
______12 Workweek Balance (FMLA) _____
26 Workweek Balance(Military)
_______ 52 Workweek Balance(FIL)
State Pays Insurance for [premium month]: Month:____________Month:____________Month____________
Does employee have enough leave to cover his/her absence? _____Yes_____No
If no, please provide employee with Voluntary Shared Leave Request Form
Revised 05/20/09
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