Request for family or medical leave or parental leave must be made, if practical, at least 30 days prior to
the date requested leave is to begin

I. Personal Data

Employee Name_______________________________ Social Security Number___________________

Home Address______________________________________________ Phone No. _______________

Employing Department_________________________________ Supervisor______________________

I am employed at another UH Component: ______Yes _______No

My spouse is employed at UH-Victoria or another UH Component: ___Yes ___No

If yes; name of UH Component:________________________________________________________

This is a joint application with my spouse. ______Yes ______No

II. Leave Request Summary: Family and Medical Leave__________     Parental Leave_________

Qualifying Condition (Mark the appropriate statement)
________ The birth of a child of the employee, and the care of the newborn.
________ The placement of a child with an employee in connection with the adoption or state-approved 
                  foster care of the child by the employee.
________ The serious health condition of a child, parent, or spouse of the employee (FML only)
________ A serious health condition of the employee (FML only)

Supporting Documents Attached
________ A medical certification from the health care provider
________ A copy of the legal orders of adoption or placement

Amount of family or medical or parental leave requested (cannot exceed 12 weeks): ______________
Start date of leave:__________________________Expected return to work date:_______________

Leave schedule for intermittent or reduced leave (If applicable; subject to supervisor's approval):

Prior family or medical leave or parental leave taken in previous 12 months:_______________weeks/days.

I understand and agree to the following provisions:

Signature of employee________________________________________ Date_____________________

III. To Be Completed by the Department

Employee's Job Title____________________________________FTE________Hire date____________

Pay type: _____Monthly _____Biweekly   Normal months worked per year:  12___9____Other________
Date of event or onset of condition___________________Last day worked_______________________
Vacation balance at last day worked _________hrs.  Sick leave balance at last day worked _________hrs.
FML/Parental Leave is approved with pay from_______________________ to______________________
FML/Parental Leave is approved without pay from_____________________ to______________________
Total weeks of approved FML or Parental Leave_________________________
For intermittent or reduced leave, the following schedule is approved:_______________________________
Family and Medical or Parental Leave taken during the previous 12 months:  _____________weeks/days
Family and Medical or Parental Leave is disapproved for the following reason (s):

Supervisor Signature___________________________________________Date_____________________

IV. Human Resources Department Acknowledgement

Signature of HR Representative___________________________________  Date__________________