PLEASE READ:  Due to an outage for APEX, this form cannot be submitted by Hennepin County employees.  Please try again Monday.  This message will be removed when employee information search functions are restored.

Sheriff's Office employees:  DO NOT USE THIS FORM.   Email Kathleen Smith to request a leave of absence.


Submit this request no later than 30 days before requested leave or as soon as you become aware of the need for leave (unless circumstances beyond your control make such advance notice impossible).

 

Enter your 9 digit Employee ID and press Search or the Tab key:

Enter the employee's 9 digit Employee ID and press Search or the Tab key:



Alternate supervisor search  

Case sensitive (e.g. upper case first letter).  Please enter at minimum the first two letters of both first and last name and press Search

First name

Last name

Email address

Department



Before you continue, please read the FMLA Employee information from the Department of Labor.

You must read the FMLA Employee information before continuing.

 

Reason for requesting leave:  (click the "help" button to the right for full descriptions) 

  • Care of a Family Member: I/Employee must care for my family member with a serious health condition which requires continuing treatment by a health care provider.
  • Employee's Own Condition: I have/Employee has a serious health condition which requires continuing treatment by a health care provider.
  • Childbirth, Adoption, or Foster Care: I/Employee must be absent from work due to childbirth, adoption or placement of a foster child in my/his/her custody. 
  • Care of a Covered Service Member: I/Employee must be absent from work as a spouse, son, daughter, parent, or next of kin to care for a “member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness.” The leave described in this paragraph shall only be available during one single 12-month period. 
  • Qualifying Exigency: I/Employee must be absent from work, because of a qualifying exigency arising out of the fact that my/his/her spouse, or a son, daughter, or parent is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation. 

I/my employee request to use time as follows:

(Note: The FMLA portion of leave for Childbirth, Adoption or Foster Care must be taken as a block of time.


I understand that:
1.  My absence from work is not considered FMLA-time unless approved by the Leave and Accommodation Management (LAM)
Office.
2.  Hennepin County Human Resources rules (or applicable labor agreement) apply to my absences.
3.  If I use leave for purposes other than those set forth in my leave request, my absence may not be approved or protected by FMLA.
4.  The LAM Office may contact the health care provider for purposes of clarification and authentication.

 

Sign and Submit:
By typing my name in the following box I am signing my name and agreeing to the terms and conditions stated above.  I certify the information I have provided is correct to the best of my knowledge, and that this information will be used for the purpose of processing my FMLA/Medical leave of absence request. I also understand that an incomplete or inaccurate form may affect the processing of my request.

Sign and Submit:
I am completing this form for someone else, but by typing my name in the following box I am signing my name and certifying the information I have provided is correct to the best of my knowledge.