Protected Leave Request Form

(Unpaid Leave)


This form is intended for employees needing to request an unpaid leave of absence under the Family Medical Leave Act (FMLA) or Oregon Family Leave Act (OFLA). If you have filed or intend to file a Paid Family and Medical Leave claim, do not complete this form.


FMLA provides eligible employees with up to 12 weeks of unpaid, job-protected leave.


For more information regarding leaves, please visit https://hr.uoregon.edu/employee-leaves.

Notice of Leave

By submitting this protected leave request form you have been made aware that a notification of leave will be sent to your supervisor and payroll administrator.

Have you filed a PFML claim with The Standard?*


If you intend to file or have filed a Paid Family and Medical Leave (PFML) claim with The Standard, do not complete this form.

Employee Information

9 digit number beginning with 95

Preferred Method to Receive Leave Communications*

Please watch this email inbox for time sensitive communications regarding your leave of absence. All communications from our office will be sent to this email address.

Please Select Your Employee Group*

Department Information

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Please provide details of how you report your worked time and accrued leave usage to your department.

Leave Information

Frequency of Leave*

HR approves eligibility for FMLA/OFLA leave, but does not approve work schedules or assignments, unless specified by the employee’s healthcare provider as a restriction or accommodation

Will you use accrued leave during FMLA/OFLA leave?*

By completing this form, you are acknowledging that you are seeking unpaid protected leave under FMLA and/or OFLA and that you may supplement your FMLA/OFLA leave with accrued paid leave for continuation of income in accordance with collective bargaining agreements and UO policies.

Reason for Leave*

The following leave reasons will no longer be covered under OFLA and must be covered under PFML instead:


  • Birth, adoption, or foster placement.
  • A family member's serious health condition.
  • An employee's own serious health condition.
Is your illness/injury work related?

If the condition is due to an on-the-job injury or illness, you must report your illness/injury via the online Workplace Injury Report.

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Generally, you may use accrued sick leave or other type of accrued leave to receive pay while taking bereavement leave. However, some employees are eligible for paid bereavement leave that is covered under Collective Bargaining Agreements.

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Please enter "N/A" if continuous bereavement leave is requested.

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Please note that your leave dates may be updated based upon a medical certification from your healthcare provider.

Please note that your leave dates may be updated based upon a medical certification from your healthcare provider.

By checking the box below, I attest affinity as a qualified family member under ORS 659A.150 and that all information provided is true and accurate to the best of my knowledge.

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