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Online Student Application

Two easy steps to register

Request for Leave of Absence under the Family and Medical Leave Act


  • Employee should complete this request form, and
  • Submit the appropriate Certification Form to the ADA/504 Coordinator

Under the provisions of the FMLA, employees are entitled to up to twelve weeks of leave per twelve-month period under particular circumstances that are critical to the life of an employee or family member. The FMLA also provides certain military family leave entitlements. The following links will direct you to the FMLA Policy and Employee Guide to FMLA for more information on your rights and responsibilities under FMLA.

Determination of eligibility for leave under the FMLA, and/or additional documentation or clarification of submitted documentation may be required prior to making a final FMLA determination to approve or deny an FMLA Leave of Absence request.

For any questions about benefits during leave, please contact Human Resources at extension 2615. Requests for FMLA Leave of Absence should be submitted at least 30 days prior to the requested leave (unless leave is unforeseen, in which case submit the form as soon as practical and within 15 days).
Personal Information
  1. Note: Select when you would like to start your services.
  2. Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
Local Address
  1. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information


    The reason for the FMLA Leave of Absence request is (select the most appropriate choice) * (Selection is Required)
    My time off work is expected to be (select the most appropriate choice): * (Selection is Required)
    Benefits participation during unpaid FMLA Leave of Absence (please select an answer below regarding benefits) * (Selection is Required)
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