Texas Tech University Health Sciences Center Logo

Family and Medical Leave Act (FMLA) Leave Application


As a TTUHSC team member, you are to apply for Family and Medical Leave Act (FMLA) Leave coverage for FMLA Leave qualifying conditions/events requiring your absence from work. 30 days advance notice is requested when applying for FMLA Leave. If 30 days advance notice is not possible, notice is to be provided as soon as practicable. Refer to TTU System Regulation 07.12; Employee Leave for additional information on the Family and Medical Leave Act (FMLA Leave).

Reporter & Campus Information

 
Enable additional features by logging in.
Learn more
Name of person filling out Application.
Learn more
e.g. Self, Supervisor, HR, Spouse....
Email address must be of a valid format.
Learn more
To receive an email copy of application
This field is required.
This field is required.

Team Member Information

Involved party 1

FMLA Information

Note: Failure to provide complete information may result in the delay and/or denial of FMLA Leave protection.

Reason for FMLA request:(Required)
You must make at least one selection.
This field is required.
This field is required.
This field is required.
This field is required.
If to care for a child, is the child under the age of 18?
This field is required.
Do you have prior state service other than your employment TTU/TTUHSC?(Required)
This field is required.
Is this the results of an On-The-Job injury?(Required)
This field is required.
Is your Spouse employed by TTUHSC?(Required)
This field is required.
Have you taken FMLA Leave in the past 12-months?(Required)
This field is required.

Supporting Documentation and/or Certification of Health Care Provider

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission