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University of Houston System Family and Medical Leave / Parental Leave Request
 

Summary: University of Houston System
Family and Medical Leave / Parental Leave Request
Employee Information:
Name: ___________________________________________________________ Empl ID: _______________________________
Home Address: _____________________________________________________ State _______________ Zip _______________
Department: ______________________________________________________ Campus: _______________________________
Supervisor Name ___________________________________________________ Telephone # ____________________________
Request for: 0 Family and Medical Leave -or- 0 Parental Leave
Request
Leave Request Summary
Is this a joint application with a spouse who is also a UH employee? 0 Yes 0 No
Is the qualifying condition due to the birth or placement of a child with you for adoption or foster care? 0 Yes 0 No
Please indicate: 0 Birth -or- 0 Adoption -or- 0 Foster Care
Anticipated birth or placement date: _____________________________________________________________________
Is the qualifying event due to Military Leave: _____ Active Duty Leave _____Military caregiver leave? 0 Yes 0 No
Active duty: Qualifying exigency _____________________________ Relationship: _______________
Military caregiver: Certification of health care provider: 0 Yes 0 No Certification for next of kin? 0 Yes 0 No
Is the qualifying condition due to the serious health condition of a child, parent, or spouse of the employee? 0 Yes 0 No
If leave requested for serious health condition of dependent, please provide the following information:
Name: ___________________________________ Relationship _________________________ DOB (if child) __________

  

Source: Azevedo, Ricardo - Department of Biology and Biochemistry, University of Houston

 

Collections: Biology and Medicine; Environmental Sciences and Ecology