UT Human Resources and Talent Development

Family Medical Leave Act Request Forms

*Effective July 1, 2016*

Faxed and/or uncompleted copies of the "Certification By Health Care Provider" forms cannot be accepted by Human Resources. Please submit the original completed "Certification By Health Care Provider" form.

Watch for the determination of your request on your official UT email address.

Employee FMLA Application and Certification
Family Member FMLA Application and Certification

Military Family Leave Forms
Certification of Qualifying Exigency (WH-384)
Certification for Serious Injury or Illness of Covered Servicemember (WH-385)





Last Updated: 7/11/17