FMLA Supplemental Pay – Change Request Form for Union Employees

This form is for SEIU/1199 union members (BU2/BU4) only.

Complete this form if you have taken FMLA related absence(s) and would like to use your accrued PTO/Sick time to supplement it. This form is not needed if you have exhausted your PTO/Sick time. Your accrued vacation time will be used automatically. Only past dates will be accepted. Future dates are ineligible and will not be permitted.

Name as listed in myURHR(Required)

First

Last

Employee ID number (6 digits)(Required)

Phone number (with area code)(Required)

Personal email address

Department name

Manager name

First

Last

Date(s)(Required)

Please list the FMLA dates (MM/DD/YYYY) you have already taken. Only past dates will be accepted. Future dates are ineligible and will not be permitted.

Employee Acknowledgment

By signing below, I understand the information provided and acknowledge that my accrued leave balances will be adjusted accordingly. I authorize the use of my accrued PTO/sick time for my FMLA absence(s) taken as noted above. If that time is exhausted, my vacation accrued time will be used automatically.

Employee signature(Required)

Form submission date(Required)