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2026 FMLA Request Form - HCI Facility Admin

Leave of Absence Intake Form (FMLA, Worker's Comp, Personal Leave of Absence)

Please provide complete information and submit for timely processing of this leave request.
1. Please provide the employee's demographic information and leave of absence request detail. *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid date format of MM/DD/YYYY.
calendar
2. Typical Work Schedule  *This question is required.
3. What type of leave has been requested?
(some leaves may run concurrently, please check all that apply) *This question is required.
4. Reason for Leave Request *This question is required.
5. Please attach any communications or documents pertaining to the request that DO NOT include PHI.
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