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).

Download and Read About UB's FMLA Procedures

Download the Form

FMLA Leave Request
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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?

Claudia Samulski.

Claudia Samulski

State Benefit Services

Phone: 716-645-4487

Email: samulski@buffalo.edu

Zachary Jenney.

Zachary Jenney

RF Benefit Services

Phone: 716-645-4439

Email: zjenney@buffalo.edu

Joyce Weeman.

Joyce Weeman

Benefits Specialist

UB Foundation

Phone: 716-645-8731

Email: joycewee@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: December 2009

Owner: Human Resources