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
120 Crofts Hall
North Campus

Need help completing the form?

Send email, phone or submit a question

Claudia Samulski

Claudia Samulski

State Benefit Services

Phone: 716-645-4487


Zachary Jenney

Zachary Jenney

RF Benefit Services

Phone: 716-645-4439


Joyce Weeman

Joyce Weeman

Benefits Specialist

UB Foundation

Phone: 716-645-8731


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Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: December 2009

Owner: Human Resources