Employee Name	Enter employee name	Employee ID No. Enter employee ID No.
Department	Enter department
Please enter the hours of FMLA used for each day. Daily hours should not exceed 8 per da y unless the employee is normally scheduled to work over 8 hours. For FMLA usage, the week is Sunday – Saturday
Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Click here to select a date	Click here to select a date	Click here to select a date	Click here to select a date	Click here to select a date	Click here to select a date	Click here to select a date
FMLA hours	FMLA hours	FMLA hours	FMLA hours	FMLA hours	FMLA hours	FMLA hours
Click here to enter hours	Click here to enter hours	Click here to enter hours	Click here to enter hours	Click here to enter hours.	Click here to enter hours	Click here to enter hours
Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Click here to select a date	Click here to select a date.	Click here to select date	Click here select a date	Click here to select a date	Click here to select a date	Click here to select a date
FMLA hours	FMLA hours	FMLA hours	FMLA hours	FMLA hours	FMLA hours	FMLA hours
Click here to enter hours	Click here to enter hours	Click here to enter hours	Click here to enter hours	Click here to enter hours	Click here to enter hours	Click here to enter hours
Comments:
Click here to enter comments
Submitted by:	Click here to enter name	Please return Correction Form to Human Resources: Fax: 387-3441 Email: hr-hris@wmich.edu Questions? Phone: 387-3620
Phone Number	XXX	-	XXX	-	XXXX
Date:	Click here to select a date