To submit the completed Sedgwick County Family Medical Leave Request Form, you can use the following methods: Email the form to FMLA@sedgwick.gov, fax it to 316-941-5132, or deliver it to your Human Resources department. Ensure that you notify your department forty-eight (48) hours prior to your date of return and submit a completed Return to Work Certification Form before resuming work.

Employees must submit the appropriate Certification of Health Care Provider form within 15 calendar days of the request. Intermittent leave requests are valid for six months. Employees must notify their department forty-eight hours prior to their date of return.

The Sedgwick County Family Medical Leave Request Form allows employees to request leave under the Family Medical Leave Act (FMLA). This form ensures that employees provide necessary information for leave related to their health or the health of a family member, the birth or adoption of a child, or military-related exigencies. By completing and submitting this form, employees can secure the leave benefits to which they are entitled under FMLA, while also complying with documentation requirements set by Sedgwick County.

• 1. Employee Name: The full name of the employee requesting leave, including first, middle, and last names.
• 2. EE#: The employee identification number.
• 3. Cell#: The employee's cell phone number.
• 4. Home Address: The employee's home address.
• 5. Department/Division: The department or division where the employee works.
• 6. Mailing/Street Address: The mailing or street address where correspondence can be sent.
• 7. Home Email: A non-County email address that the employee can access while on FML.
• 8. City, State, Zip: The city, state, and zip code for the employee's address.
• 9. Spouse's Information: If the employee's spouse is a County employee, their name and department.
• 10. Leave Type: Selection of either Intermittent FML or Continuous FML.
• 11. Reason for Request: The reason for requesting leave, including a checklist of options related to the employee's or family member's condition, birth/adoption, or military duty.
• 12. Expected Leave Dates: The expected start and return dates for the leave.
• 13. Certification: A certification statement acknowledging the terms and conditions of FMLA leave.
• 14. Authorization: Authorization for a representative to contact the health care provider for authentication and clarification of provided information.
• 15. Employee Signature: The employee's signature and the date of signing.

If you fail to submit this form, you may jeopardize your eligibility for leave under the Family Medical Leave Act.

• Loss of Leave Benefits: You may not receive the benefits provided under FMLA, impacting your ability to take necessary leave.
• Job Security: Failure to submit the form may affect your job security, as you may not be granted protected leave.
• Health Insurance Payments: You may be required to reimburse Sedgwick County for any health insurance premiums paid during your leave period.

• 1. Serious Health Condition: Request leave for your own serious health condition.
• 2. Birth or Adoption: Request leave for the birth, bonding, or adoption of a child.
• 3. Family Care: Request leave to care for a spouse, child, or parent with a serious health condition.
• 4. Next of Kin: Request leave as the next of kin of a covered service member with a serious injury or illness.
• 5. Military Duty: Request leave for a qualifying exigency due to a family member's active duty status.