FMLA | Broward Health

Employee Information Section:

Full Name

Employee ID

Phone

Personal Email Address

Address

Supervisor

Title

Department

Shift

Will you be Filing for Short Term Disability?

YES

Are you a PFP Leader?

YES

Select A Facility

Time off Work Section:

Select The Most Appropriate Reason:

On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week; examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatment/appointments). *Employees must make reasonable efforts to schedule leave for planned medical treatments and appointments so as not to unduly disrupt the employer's operations.

Several continuous days, weeks, or months off work.

Start Date of Anticipated Leave (mm-dd-yyyy):

Anticipated Date of Return (mm-dd-yyyy):

Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and must comply with an employer's normal call-in procedure. I have notified my supervisor of my need for Family Medical Leave and will send HR an approved PL Request Form.

YES

Events

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FMLA Eligibility Request