FMLA Preliminary Request Form

Employee Name*
First Last
Employee UFID*
Preferred Contact Phone*
Preferred Email*
Are you a tenure-accruing faculty member?
- Yes
- No
Tenure-accruing faculty members using FMLA have the opportunity to request an extension of their tenure probationary period. Please contact your college/unit HR administrator for more information.
Anticipated or actual first date of absence*
Date Format: MM slash DD slash YYYY
What type of FMLA are you requesting?*
- The birth of a child, or placement of a child with you for adoption or foster care.
- Your own serious health condition.
- Because you are needed to care for your spouse, child, or parent due to his/her serious health condition.
- Because of a qualifying exigency arising out of the fact that your spouse, son or daughter, or parent is on covered active duty or call to covered active duty status with the Armed Forces.
- Because you are the spouse, son or daughter, parent, or next of kin of a covered servicemember with a serious injury or illness.
Person submitting this form
- Same as employee
Name*
First Last
Email*

Upon submission, this form is sent to FMLA@hr.ufl.edu for review.

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