Request for Family/Medical Leave
1. I
request family/medical leave beginning
for the following purpose:
The birth of my child or the placement of a child with me for adoption or foster care
A serious health condition that makes me unable to perform the essential functions of my job
A serious health condition affecting my spouse, child, or parent for which I am needed to provide care
The death of an immediate family member (see definition of immediate family at http://www.dexform.com)
2. T
otal hours of anticipated absence from UNL
3. Please show number of hours of each type of leave to be taken.
4. If leave of three consecutive days or more has been
taken for any of the above listed purposes within the past 12
months, please indicate dates:
Please note that leave of three consecutive days or more taken for any of the above listed reasons may apply toward the twelve weeks
of eligibility for leave provided under the Family/Medical Leave Act.
I understand:
* That I may be requested to provide medical documentation of my illness or the illness of my immediate family member
* That I may be requested to provide a medical release upon my return to work
* That I am responsible to consult UNL Benefits Office for any unpaid portion of this leave.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you
not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s
family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Approval of Immediate Supervisor
Approval of Dean/Director
Note to Dean/Director: Please send completed original forms to Department of Human Resources, 407 Canfield Administration, 0438 and
copies to employee and department respectively.
Questions about thi
s form or about
UNL’s Famil
y/Medical Leav
e Policy may be di
rected to Hu
man Resource
s
402-472-3101 or hr[email protected]du
Revised February 2011
