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Get Yale New Haven Hospital Request for Family and/or Medical Leave (FMLA) Physician Certification Form

in locked cabinets with only designated persons having access. TO BE COMPLETED BY EMPLOYEE: Employee Name Title Employee SS# ________________Employee ID # Department Employee Address: ______________________________________________Date of Hire:____________ (Note, this address will be used to respond to this request) Current Status: • o Full-time o Part-time o Casual Manager Name:______________________ I am requesting a Family and Medical leave due to:* o the birth of my child, or the .

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