El Mirage

Welcome to the Gov-Smart profile for El Mirage! This is the one-stop place where all public institution services are centralized and standardized, providing you with quick and efficient access to the information and procedures you need. Through this platform, you will find all the necessary resources in one place, eliminating the need to navigate through multiple websites or visit different departments. From managing important documents to monitoring public expenditures, Gov-Smart offers you all the tools to simplify your life and improve the efficiency of public services.

Official Website

Family Medical Leave Act (FMLA) Leave Request Form

0% completed

Employees seeking to use FMLA leave are required to provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable and such notice is practical. For example, if the employee is scheduled for surgery in two months, the need for leave is foreseeable and at least 30 days advance notice is required. If 30 days advance notice is not possible because the situation has changed or the employee does not know exactly when leave will be required, the employee must provide notice of the need for leave as soon as possible and practical. When the employee has no reasonable excuse for not providing at least 30 days advance notice, the employer may delay the FMLA leave until 30 days after the date notice is provided. When the employee could not have provided 30 days advance notice but has no reasonable excuse for not providing a shorter period of advance notice, the employer may delay the FMLA leave by whatever amount of time that the employee delayed in notifying the employer. To request FMLA leave, complete the form and return to Human Resources.

Employee’s Name *

Employee’s Job Title *

Phone *

Email *

The reason for this FMLA leave request is (select the most appropriate box):

Birth of a son or daughter and to care for the newborn child.

Placement with the employee of a son or daughter for adoption or foster care

To care for the employee's spouse, son, daughter or parent with a serious health condition.

A serious health condition that makes the employee unable to perform the functions of the employee's job.

A qualifying exigency arising out of the fact that the employee's spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status).

To care for a covered service member with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered service member.

Time off work is expected to be (select the most appropriate box):

For a continuous block of time (several continuous days, weeks or months off work)

For a reduced work schedule (change in work schedule needed—fewer hours per day or fewer hours per week).

On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week; examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatment/appointments).

I understand that FMLA leave of absence is a leave without pay; if my leave is designated as FML I will be required to use my paid leave time until leave concludes, or my accrued leave balances are depleted. The type of paid leave that I may use is dependent upon the reason for FML. All leave used must meet the requirements of City of El Mirage Personnel Manual. Additional information about FMLA rights and responsibilities will be provided in writing to you within five business days of Human Resource’s receipt of this form (unless already provided). Determination of eligibility for leave under the FMLA, and/or additional documentation or clarification of documentation, may be required prior to making a final FMLA determination to approve or deny an FMLA leave request.

Created by AIPSS

El Mirage

Family Medical Leave Act (FMLA) Leave Request Form

Employee's Information

Details