Forms > Family Medical Leave Act Form

Family Medical Leave Act Form

A family medical leave act form is usually used whenever there is need for an employee to be given leave from work as a result of family related reasons. The form contains information such as the duration of the leave, whether it is paid or unpaid and the date for reporting back.

Sample Family Medical Leave Act Form

Name of employee: ______________________________

Department: __________________________________

Social Security Number: _________________________

Date leave request was issued: _______________________________

The category of leave requested

Paid leave ________

Unpaid leave _________

Clearly describe the reason for leave requested and the level of family member/members involved.

If family member, describe relationship_________________________________

Requested commencement date of leave: __________________________

Stated date of reporting back to work: ____________________________

Address of the residence during leave: ____________________________

Telephone number to be used during leave: __________________________

I agree and confirm that am taking the above requested leave and the information provided is true and accurate. I am fully aware of the disciplinary measures for breach of this leave agreement.

Signature: _____________________________

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