FMLA Request for Leave

Request leave for a state, RF or UBF employee to go on a medical leave of absence under the Federal Medical Leave Act (FMLA).

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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Human Resources
University at Buffalo
Townsend Hall
205 Hayes Road
Buffalo, NY 14214

Need Help Completing the Form?

  • avatar.

    UB HR Leaves

    State Benefit Services

    Phone: 716-645-7777


  • Zachary Jenney.

    Zachary Jenney


    Research Foundation Benefit Services

    Phone: 716-645-4439


  • Joyce Weeman.

    Joyce Weeman

    Benefits Specialist

    UB Foundation

    Phone: 716-645-8731


Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: December 2009

Owner: Human Resources