Please fill out this form when requesting any type of leave, including leave eligible under the Family Medical Leave Act (FMLA). This form is in lieu of a personal letter requesting leave. If you have any further questions, please call 379-4806.
Employee: Please ask your doctor to complete this form when you are planning to return to work from a Medical Leave. This completed and signed form must be turned in to Human Resources before or upon your return to work. Thank you.