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Get Request For Family And Medical Leave - Utexas

12-475-8099 FAX 512-471-7008 REQUEST FOR FAMILY AND MEDICAL LEAVE Employee Name: UT EID: Home Address: City: State: Zip: Home Phone: Department Contact: Other Phone: Office Phone: Family and Medical Leave: Family and Medical Leave may be used for the following circumstances (check appropriate box): Birth and Care of your child or a child for whom you stand in loco parentis.* Adoption or Foster Care Placement of your child or a child for whom you stand in loco parentis.* My child is.

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