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FMLA Request Form

FMLA provides 12 weeks of job-protected leave in a 12 month period to eligible employees. To qualify for FMLA you must have worked at least 12 months (need not be consecutive), and also have worked at least 1,250 hours during the 12 months prior to the start of the FMLA leave.

Please fill out the following.

Serious health condition that makes the employee unable to perform the essential functions of his/her job.

To care for the employee’s child after birth, or placement for adoption or foster care.

Incapacity due to pregnancy, prenatal medical care or child birth

To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition.

Qualified exigencies for an eligible employee whose close family member is on active duty.



A single block of time

An intermittent/reduced work schedule

Contact Us

Human Resources Benefits Office

Campus: Hill Hall rooms 339, 341, 343

Mail: Dept. 3422

1000 E. University Ave.

Laramie, WY 82071

Office Hours: Monday - Friday

Regular: 8:00 am - 5:00 pm

Summer: 7:30 am - 4:30 pm

Phone: 307.766.2215

Fax: 307.766.5636


1000 E. University Ave. Laramie, WY 82071
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