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Employee Application for Leave under FMLA

Employee Application for Leave under FMLA 2026

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The document is an 'Employee’s Notice of Injury' form from the Research Foundation of The City University of New York. It is designed for employees to report work-related injuries by providing personal, job, and injury information. Employees must complete the form, including details about the incident, medical attention received, and any witnesses, and submit it to the Department of Human Resources.

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Click ‘Get Form’ to open the Employee Application for Leave under FMLA in the editor.
Begin by entering your personal information, including your Employee ID, name, address, and contact details. Ensure all fields are filled accurately to avoid delays.
In the Job Information section, provide details about your employment status (full-time or part-time), job title, work location, and supervisor's name. This information is crucial for processing your leave request.
Next, move to the Injury Information section. Fill in the date and exact location of the injury, along with a detailed description of how it occurred. Be specific about the nature of the injury and any equipment involved.
Complete the Medical Information section by indicating if you received medical attention and providing details about your healthcare provider. Include any prior injuries or conditions that may be relevant.
Finally, review all entered information for accuracy before signing at the bottom of the form. Once completed, submit it directly through our platform for efficient processing.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (141 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What reasons for leave qualify under FMLA?

The FMLA protects leave for: The birth of a child or placement of a child with the employee for adoption or foster care, The care for a child, spouse, or parent who has a serious health condition, A serious health condition that makes the employee unable to work, and.

How do I write a letter for FMLA?

Bring the form with you. Tell them what you are experiencing, why you are experiencing it, and how it is affecting your health and well being. Let them know that you think you would benefit from time off work, but need their support to do so.

Can FMLA forms be emailed to employees?

Administrators may choose to deliver Family and Medical Leave Act (FMLA) information, including the FMLA packet, reminder notices, etc., to an employees email address, provided the employee agrees beforehand to receive information electronically.

Can my employer fire me for applying for FMLA?

Short answer: If your leave is protected (CFRA, Pregnancy Disability Leave, FMLA, paid sick leave, or leave as a reasonable accommodation under FEHA), your employer cannot lawfully fire you because you used it or because you asked for it.

How do I tell my employer I need FMLA?

Certification forms. The FMLA does not require the use of any specific certification form. The Department has developed optional forms that can be used for leave for an employees own serious health condition (WH-380-E) or to care for a family members serious health condition (WH-380-F).

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