Elon University
REQUEST FOR LEAVE UNDER THE FAMILY AND MEDICAL LEAVE ACT
NAME_____________________ SOCIAL SECURITY NUMBER ___________________
DATE OF HIRE _____________ DEPARTMENT________________________________
LEAVE REQUESTED FOR:
____ The birth of a child or placement of a child with you for adoption or foster care
____ A qualifying exigency arising out of the fact that your ____ spouse;
_____son/daughter; ______ parent is on active duty or call to active duty status
in support of a contingency operation as a member of the National Guard or
Reserves
____ You are the ____ spouse; _____son/daughter; ______ parent; _______ next of
kin of a covered service member with a serious injury or illness*
____ You are needed to care for your ____ spouse; _____child; ______ parent due to
his/her serious health condition *
____ Your own serious health condition * **
*
Must be supported by a medical certificate prior to commencement of the leave
* ** A medical “fitness to return to work” certificate is required before employee can
return to work.
LEAVE REQUESTED FROM ________________ TO __________________
PLEASE EXPLAIN THE REASON FOR REQUESTING THE LEAVE BELOW
NAME_____________________ SOCIAL SECURITY NUMBER ___________________
DATE OF HIRE _____________ DEPARTMENT________________________________
_________ I am requesting leave for Monday through Friday each week of the time period
identified above.
_________ I am requesting leave for only part of each week being requested above. (Please
explain below your specific plans for working each week during the requested
leave).
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
The Family and Medical Leave Act requires that employees be given the option of continuing