FMLA | Broward Health

Full Name

Employee ID

Phone

Address

Supervisor

Title

Department

Shift

Will you be Filing for Short Term Disability?

YES

Are you a Manager?

YES

Select A Facility

Reason (select one explanation)

Your own serious health condition

Care of your spouse (due to serious health condition)

Care of your child (due to serious health condition)

Care of your parent (due to serious health condition)

Birth of a child or care of new born child

Placement of a child with you for adoption or foster care

Qualifying exigency related to SPOUSE active duty status in support of a contingency operation as a member of the National Guard or Reserves.

Qualifying exigency related to CHILD active duty status in support of a contingency operation as a member of the National Guard or Reserves.

Qualifying exigency active duty status in support of a contingency operation as a member of the National Guard or Reserves

Qualifying exigency related to PARENT active duty status in support of a contingency operation as a member of the National Guard or Reserves.

Military caregiver leave for SPOUSE who is a covered service member with a serious injury or illness.

Military caregiver leave for CHILD who is a covered service member with a serious injury or illness.

Military caregiver leave for PARENT who is a covered service member with a serious injury or illness.

Military caregiver leave for NEXT of KIN who is a covered service member with a serious injury or illness.

Select The Most Appropriate Reason:

Several continuous days, weeks, or months off work.

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.

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

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