Date: Initials: Family & Medical Leave Request Form

Family & Medical Leave Request Form

I. EMPLOYEE INFORMATION

Employee Name:

PID:

Dept. Name:

Job Title:

Information regarding your leave will be sent to your UNC-CH email account unless you request in writing that we use an

alternative email address. Please provide your preferred contact information below.

Email:

Date of Hire:

For Faculty Only:

Phone:

Permanent

SHRA

Full-Time

Temporary

EHRA Non-Faculty

Part-time

12-Month Appt.

9-Month Appt.

Teaching Responsibilities:

Yes

No

Work Schedule:

Supervisor:

Supervisor Email:

HR Rep/Officer:

HR Rep/Officer Email:

TIM Administrator:

TIM Admin Email:

II. LEAVE REQUEST

Choose one:

New Request

Request for Extension of FMLA Leave

Reason for Leave:

Birth of a Child (Choose One):

Birth Parent

Non-Birth Parent

Adoption

Foster care or another legal placement

Your own serious health condition (not work related)

To care for your immediate family member due to their serious health condition

Qualifying exigency because a family member is on or has been called to covered active duty in the Regular Armed Forces

(including the National Guard and Reserves) to a foreign country

To care for a current member of the Armed Forces (including the National Guard and Reserves) or a covered veteran with a

serious injury or illness if the employee is the spouse, child, parent or next of kin of the covered service member

Leave Begin Date:

Last Day Worked (continuous leave only):

Type of Leave Requested (Check One):

Leave End Date:

Return-to-Work Date:

Continuous/Block Leave

Intermittent Leave

Reduced Schedule

If you are requesting intermittent leave, please indicate how much intermittent leave you are requesting and estimate the

frequency and duration of absences. If you are requesting a reduced work schedule, please indicate the days and the number of

hours per day you are requesting to work.

Rev. 11/11/2022

Equal Opportunity Employer

Page 1 of 2

III. REQUIRED DOCUMENTATION (Due within 15 days of submitting this form)

Your own health condition, including pregnancy

disability and childbirth recovery

To care for your child following birth or

adoption/foster care placement

Family member¡¯s health condition, including spouse¡¯s

pregnancy disability and childbirth recovery

Qualifying Exigency

Military Caregiver Leave

Medical Certification (Form WH-380E for employee)

Birth Certificate, Adoption Order, Foster Care Placement Agreement,

Custody Order, or Letter of Placement

Family Member Medical Certification (Form WH-380-F)

Certification of Qualifying Exigency U.S. Department of Labor For Military

Family Leave (Form WH-384)

;



IV. EMPLOYEE CERTIFICATION AND SIGNATURE

For leave-earning employees - If you were approved for FMLA leave within the last 12 months, please confirm that all your FMLArelated absences are entered in TIM and have been coded as ¡°FMLA leave¡± with your departmental TIM Administrator.

I certify that the information I have provided on this form is accurate and complete. I have read and understand the Family &

Medical Leave information available to me on the hr.unc.edu website. I understand that FMLA leave runs concurrently with paid or

unpaid leave. If my request for a leave of absence is approved, I understand that I must abide by all the terms and conditions of my

leave of absence.

If I am returning from a continuous leave of absence for my own medical condition, I understand that I am required to submit

return-to-work documentation to HR prior to reinstatement. If I am unable to return to work on the specified date, I am to notify

HR of the change. Failure to notify HR may result in my being absent without authorization. Any falsification of information may

lead to appropriate administrative action, up to and including dismissal from UNC-CH.

Employee Signature:

Date:

V. SUPERVISOR ACKNOWLEDGEMENT

I understand that this employee has requested job-protected leave under the FMLA and that FMLA leave is confidential.

Supervisor Signature:

Date:

VI. ROUTING OF DOCUMENTATION

All leave documentation must be submitted in ConnectCarolina (SelfService > My Benefits Tile > Leave > Submit a

Leave Document). For links to leave forms and instructions on how to Submit a Leave Document in ConnectCarolina,

please visit the Benefits & Leave forms page online at . If you have questions or

need assistance, please call 919-962-3071 or send an email to leave@unc.edu.

Rev. 11/11/2022

Equal Opportunity Employer

Page 2 of 2

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