DEPARTMENT OF ECONOMIC OPPORTUNITY

REQUEST FOR LEAVE OF ABSENCE

PLEASE NOTE: Family Medical Leave Act (FMLA) leave usages will be automatically counted as part of your entitlement under Federal Law.
NAME(Last, First, Middle)	PEOPLE FIRST ID	COST CENTER NO.
CLASS TITLE	POSITION NO.	LOCATION
PROCESS AREA	PROCESS UNIT	Please Indicate Leave Type:
PERSONAL MEDICAL (FMLA)	EDUCATIONAL
PARENTAL (FMLA)	MILITARY
COMMENCING DATE	ENDING DATE	FAMILY MEDICAL (FMLA)	OTHER
WORKER'S COMPENSATION (FMLA)	(Explain Below)
EMPLOYEE'S CERTIFICATION OF FMLA NOTIFICATION, (If Applicable)

I CERTIFY THAT I HAVE BEEN NOTIFIED OF MY RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT

Employee's Signature:
Date:
I REQUEST THAT I BE RETURNED TO:	MY PRESENT POSITION	ANOTHER POSITION IN MY CLASS	ANOTHER POSITION IN A LOWER CLASS
EMPLOYEE'S SIGNATURE	DATE
TO BE COMPLETED BY EMPLOYEE'S SUPERVISOR - IF LEAVE IS APPROVED, THIS EMPLOYEE WILL BE RETURNED TO THE POSITION IDENTIFIED BELOW.
CLASS TITLE	POSITION NO.	LOCATION
SUPERVISOR'S

RECOMMENDATION	APPROVED AS REQUESTED	DISAPPROVED

(STATE REASON BELOW)	ALTERNATE RECOMMENDATION
COMMENTS:

SUPERVISOR'S SIGNATURE	DATE
PROCESS MANAGER RECOMMENDATION
APPROVED AS REQUESTED	SUPERVISOR'S RECOMMENDATION APPROVED	DISAPPROVED

(STATE REASON BELOW)	ALTERNATE RECOMMENDATION
COMMENTS

PROCESS MANAGER'S SIGNATURE	DATE
TO BE COMPLETED BY DEPUTY DIRECTOR/DESIGNEE
APPROVED AS REQUESTED	SUPERVISOR'S RECOMMENDATION APPROVED	ALTERNATE RECOMMENDATION	DISAPPROVED
DEPUTY DIRECTOR/DESIGNEE SIGNATURE	DATE

INSTRUCTIONS (See Reverse Side)

INSTRUCTIONS

This form will be used to request a Leave of Absence with or without pay in accordance with The Federal Family and Medical Leave Act (FMLA), Chapters 60K-5, 60K-6, 60K-7, and 60L-23, F.A.C. Submit in duplicate to your supervisor at least thirty (30) days prior to leave commencing date: Division Directors/designees must forward a completed DEO Form HRM-1, Personnel Action, along with DEO Form HRM-15, Request for Leave of Absence, with all supporting documents to the Bureau of Human Resource Management.

All supporting documents, e.g. Medical Statement, Military Orders, Institution's Acceptance Certificate, must be attached to the original copy of this form before submission for approval.
PERSONAL MEDICAL, FAMILY MEDICAL, AND PARENTAL LEAVES OF ABSENCE
The State's contribution for full-time and part-time employees enrolled in the State Group Insurance Program shall continue up to six months for employees who have been granted a personal medical, family medical, and/or parental leaves of absence. However, a medical statement must be provided as supporting documentation and must accompany this form. Employee insurance contributions must be paid by personal check(s) or money order(s), unless they request personal leave usage during the period of leave to continue insurance coverages through payroll deduction. Otherwise, coverage will cease.

Note:	Family Medical Leave Act (FMLA) leave usage will be automatically counted as part of your entitlement during the consecutive twelve (12) month period mandated under Federal Law. Under Agency policy, the twelve (12) month period begins on the date the employee first uses qualifying leave after being notified by his or her supervisor or appropriate authority of his or her rights under the law.
OTHER LEAVES OF ABSENCE

To continue current insurance coverage’s while on other leave of absences, employees will be required to submit personal check(s) or money order(s), unless the employee request personal leave usage during the period of leave to continue insurance coverage through payroll deduction. The employee will be responsible for paying his or her regular premium plus the state’s contribution for state health and life insurance. Otherwise, coverage will cease.

All personal check (s) or money order (s) should be made payable to: Division of State Group Insurance and forwarded to the following address:

The People First Service Center

Post Office Box 863477

Orlando, Florida 32886-3477
PLEASE INDICATE SPECIFIC DATES AND/OR PERIODS OF LEAVE USAGE, AS NEEDED.

DEO Form HRM-15 (2/01)

DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

Henry, Chad

2014-10-10

FDLES J&B OIT