Complete this form before leave is taken to ensure it is considered for approval. In the event of an unplanned absence, please complete this form as soon as possible.
For FMLA or OFLA-covered leaves, the Office of Human Resources, Employee Benefits is the approver. Contact this office for assistance prior to submitting your request:
Human Resources Benefits Analyst: (541) 737-5946
For FMLA or OFLA leave, a Certification of Health Care Provider form must be completed or call the FMLA Benefits Analyst at (541) 737-5946.
If sick leave or care for a family member is requested and does not qualify for Family Medical Leave Act (FMLA) and/or Oregon Family Leave Act (OFLA), these requests may require a physician's certificate to confirm your inability to work if the leave request is for 7 days or more (for classified employees) or 15 days or more (for unclassified employees) or sooner if requested by your supervisor.
Employees: please send this form to your supervisor to request leave. If FMLA or OFLA leave is requested, your supervisor's signature acknowledges the leave; Office of Human Resources, Employee Benefits approves it.
Supervisors: please return a completed, signed, copy of this form to the employee. Keep the original form in the department along with other time and attendance records. If FMLA or OFLA leave is requested, you must send a copy of this form to the Office of Human Resources, Employee Benefits for approval and federal record keeping requirements.
Employee Benefits / Office of Human Resources
In-person delivery: 204 Kerr Administration Building
Campus & postal mail:
Employee Benefits, Center for Workplace Solutions
Office of Human Resources
Oregon State University
204 Kerr Administration Building
Corvallis, OR 97331-2132
Your Business Center Human Resources staff.
For FMLA/OFLA-covered leaves:
Office of Human Resources, Employee Benefits (541) 737-5946, FMLA@oregonstate.edu