Employee Name Enter the official name with middle initial. Department Number Enter the three digit department number. Department Name Enter formal title of the department Mailing Address Enter the forwarding address of the employee so that benefits information and tax withholding statements may be mailed to proper address, if necessary. This is important for accurate calculation of leave balances. Ill Health Check for any leave related to illness including birth of a child.
Personal Reasons Check if appropriate.
The completed FMLA application and physician's certification must be sent to Personnel Services. This leave requires an approved Workers' Compensation claim and an approved disability determination by a Workers' Compensation physician. Military A copy of the official military orders must be forwarded to Personnel Services as soon as received. If the position is still vacant and the employee wants to return within the approved leave time, they have the right to return to it. Conditional Leave for Personal Reasons - check if appropriate.