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Family & Medical Leave
FMLA Request Form
FMLA Request Form
ARP 8.45 - – LOA – Family and Medical
provides eligible employees the ability to request up to 12 work weeks (up to 26 work weeks for Military Caregiver) of job protected leave for pregnancy, childbirth, the employee’s illness or the illness of the employee’s family member. Upon receipt of a request for Family & Medical Leave, Benefit Services will verify the employee's eligibility for FMLA leave and send a letter to the employee requesting the appropriate documentation to support the request for FMLA, along with the employee's rights and responsibilities under FMLA. Notification of the request and applicable designation will be sent to the department supervisor and the unit HR Liaison. For detailed information on Family Medical Leave for NMSU employees, please visit the
FMLA webpage
.
EMPLOYEE INFORMATION
Aggie ID
*
Required
Name
*
Required
First
Last
Employee's Email Address
*
Required
Leave Requested by (include first and last name):
*
Required
Phone # of Requestor (xxx-xxx-xxxx):
*
Required
LEAVE REQUESTED
Estimated Begin Date:
- must be mm/dd/yyyy format
*
Required
Date Format: MM slash DD slash YYYY
Estimated End Date:
- must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Fieldset Description
Type of Family & Medical Leave Requested (check all that may apply):
*
Required
---- Block Time - specific start date of leave with continued time away from work until return
---- Intermittent Time - hours or days needed on occasion
---- Reduced Schedule - consistent daily hours away from work
Fieldset Description
Leave is requested for:
*
Required
--- Employee's Illness
--- Childbirth - Employee
--- Childbirth - Spouse
--- Parent's Illness
--- Spouse's Illness
--- Dependent Child's Illness
--- Domestic Partner's Illness**
--- Childbirth - Domestic Partner
--- Care for Military Service Member
--- Family Member called to Active Duty Exigency
--- Adoption/Foster Placement
**Affidavit of Domestic Partnership must be provided at the time leave is requested, if not already on file with Benefit Services. For information on Domestic Partnerships please see
http://benefits.nmsu.edu/other/domestic-partner/
.
DEPENDENT INFORMATION IF LEAVE IS REQUESTED TO CARE FOR A FAMILY MEMBER OR CHILDBIRTH FOR A SPOUSE:
Dependent's Name
First
Last
Dependent's Birth Date
- must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Dependent's Gender
--- Male
--- Female
Fieldset Description
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