Office of Human Resources

Family Medical Leave

Employee Information

Name:       Employee ID:
Telephone:
Home Address:

Leave requested for:
Self
Maternity
Adoption
Other family member

Nursing Practice Member

Supervisor's name:
Supervisor's email address:

Reporter's email address (required):

River Campus
MAIL: 500 Joseph C. Wilson Blvd.
Rochester, NY 14627

GPS/MAPS: 252 Elmwood Ave.
Rochester, NY