FMLA Request for Leave Form | Sedgwick County, Kansas

Employee Information

Name (required) First Middle Last

EE-ID#

Work Phone Number

Home Address Street City State Zip

Personal Email (required) Please provide a non-County email address you can access while on FML

Cell Phone # (required)

Department/Division

I am requesting: (required)

CONTINUOUS FML (consecutive absences due to a sudden health event)

Expected leave begin date: (required) Start date cannot be backdated more than 30 days

Expected return to work date: Return to Work Form required for Continuous FML

Employee Signature (required)

Date (required)