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
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

    Email: ub-hr-leaves@buffalo.edu

  • Zachary Jenney.

    Zachary Jenney

    Research Foundation 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