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FAMILY AND MEDICAL LEAVE RECORD
(For Department Use Only)

TO BE COMPLETED BY THE SUPERVISOR

FISCAL YEAR:  
Employee Name:  
Date Leave Commenced:  
Date Return to Work:  
 
Time (days, hours) away from work and type of leave used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The University of Minnesota is an equal opportunity educator and employer.
© 2008 University of Minnesota Duluth
2008
Comments: Judith S. Karon Webmaster: Lita C. Wallace Updated By: Tanisha C. Lee

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255 DADB, 1049 University Drive
Duluth, MN 55812
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