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
Before you continue, please read the FMLA Employee information from the Department of Labor.
You must read the FMLA Employee information before submitting this form.
Work related injuries require a First Report of Injury form. If you have not yet reported the work injury, please visit First Report of Injury.
Reason for requesting leave: (click the "help" button to the right for full descriptions)
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)
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.