FMLA Preliminary Request Form

Please select if any of the following apply:

I do not know the UFID of the employee that this form pertains toI am submitting this form on behalf of somebody else.

Submitter Information

Name

Email Address

Employee Information

UFID

First Name

Middle Initial

Last Name

Preferred Email Address

Preferred Phone Number

Anticipated or actual first date of absence

Position Classification

Tenure-accruing?

Yes

What is your leave related to?

If you do not see the reason for your leave represented here, please contact your Department, Division, or College’s Human Resource Liaison for additional information regarding your leave options. If you would like to contact the HR Benefits office directly, please go here - https://benefits.hr.ufl.edu/contact/

Please choose the option that best describes your circumstances:

I am interested in having the period of pre-natal care protected by an FMLA medical leaveI am not interested in medical leave to cover pre-natal care at this time

Please choose the option that best describes the family member for who you will be providing care and support:

Please choose the option that best describes your circumstances:

I am required to report for training exercisesI am a member of the Florida National GuardI am being deployed for long-term service in the Armed Forces

Please choose the option that best describes your circumstances:

My parent, spouse, or child is being deployed for long-term serviceMy parent, spouse, or child is a current member of the armed forces who incurred a serious illness or injury on active duty (or had such a condition which was aggravated during their service)My parent, spouse, or child is a covered veteran who incurred a serious illness or injury on active duty (had had such a condition which was aggravated during their service)

Acknowledgement

The information provided above is complete and true to the best of my knowledge. I understand that any willful misrepresentation or falsification may lead to ineligibility for these benefits and may be cause for disciplinary action, up to and including termination.

Submitting this form will initiate a formal Leave of Absence request form. You can expect to receive more information regarding your request within five business days.

UF Leave Request

Resources

Campus

Website