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.

 


If you intend to file or have filed a Paid Family and Medical Leave (PFML) claim with The Standard, do not complete this form. Follow the steps on our How to File a PFML Claim webpage.

 

Employee Information

 
 

9 digit number beginning with 95

 
 
 
 

Department Information

 
 
 
 
 
 
 
 
 
 

Leave Information

 

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

 

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.

 

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.
 
 

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

 
mm/dd/yyyy
 

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

 
mm/dd/yyyy
 

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.