Family Medical Leave

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Family and Medical Leave Policy # 2230-9

GEORGIA DEPARTMENT OF TRANSPORTATION

FAMILY AND MEDICAL LEAVE REQUEST FORM

Name of Employee____________________________________________ SS#_____________________

Work Location _______________________________________________________________________

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I request to use family and medical leave from _____________________ to _______________

for the following reasons:

Please check: _____ A. Pregnancy/birth of my child.

_____ B. Care of my newborn child.

_____ C. The adoption or foster care of a child, or care of the child after placement with me.

_____ D. A serious health condition.

_____ E. Care of my (circle one) child, spouse or parent who has a serious health condition.

Please complete:

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I request to use available leave during the period of absence as follows:

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_____ hours of annual leave _____ hours of personal leave _____ hours of sick leave

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_____ hours of State compensatory time _____ hours of leave without pay

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If you are requesting intermittent leave or a reduced work schedule, please provide details of your need for leave:

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I understand that use of family and medical leave for any combination of circumstances listed above will be limited to a total of twelve (12) work weeks in a calendar year. I also understand...