Sample FMLA Request Forms
[Pages:4]Sample FMLA Request Forms
Sample FMLA Request Form #1 ? 1 Block of Time Sample FMLA Request Form #2 ? Intermittent Leave Sample FMLA Request Form #3 ? Reduced Schedule
Sample FMLA Request Form #1 ? 1 Block of Time
TO: [Name of Director of Human Resources, Supervisor, or Other Manager]
FROM:
[Your name, Job Title]
RE: Notice of the Need for FMLA Leave
Date: [Today's Date]
This memo is to notify you of my need for leave under the Family and Medical Leave
Act. I require a leave of absence from [Start Date]
to [End Date] .
because:
I am temporarily unable to work because of my own serious health condition.
I will be caring for a family member (spouse, child, or parent) with a serious health condition.
I have attached a completed certification from a health care provider documenting my need for leave.*
It is my understanding that I am eligible for up to 12 weeks of leave per year under the Family Medical leave Act and that I will be reinstated to my job after my leave. [If you are covered by your employer's health insurance include this sentence, It is also my understanding that (Employer's Name) will continue my health insurance during my leave.]
The Family and Medical Leave Act specifies that employers must provide specific written notice to an employee of rights and responsibilities regarding leave within a few business days of when that employee gives notice of the need for leave (29 C.F.R. 825.301). I look forward to receiving this information from you.
Please let me know immediately and in writing if you require anything further from me. I appreciate your assistance with this matter.
* Although medical certification is not required unless your employer asks for it, to protect your rights fully, include this sentence and attach the certification. You do not need to disclose a diagnosis to certify your need to take leave. To access the FMLA Medical Certification form WH-380 go to:
esa/regs/compliance/whd/fmla/wh380.pdf
Sample FMLA Request Form #2 ? Intermittent Leave
TO: [Name of Director of Human Resources, Supervisor, or Other Manager]
FROM:
[Your name, Job Title]
RE: Notice of the Need for FMLA Leave
Date: [Today's Date]
This memo is to notify you of my need for intermittent leave under the Family and
Medical Leave Act. I require intermittent leave from [Start Date]
to [End
Date] . because of:
temporary absences due to my own serious health condition.
temporary absences due to caring for a family member (spouse, child, or parent) with a serious health condition.
I have attached a completed certification from a health care provider documenting my need for leave. *
It is my understanding that I am eligible for up to 12 weeks of leave per year under the Family Medical leave Act and that I will be reinstated to my job after my leave. It is also my understanding that when a health care provider certifies a need for intermittent FMLA leave for a period exceeding 30 days, an employer may not require additional certifications during that period unless a request is made to extend the leave, circumstances change significantly, or the employer receives information that casts doubt on the need for leave. (See 29 C.F.R. 825.308(b)(2)).
The Family and Medical Leave Act specifies that employers must provide specific written notice to an employee of rights and responsibilities regarding leave within a few business days of when that employee gives notice of the need for leave (29 C.F.R. 825.301). I look forward to receiving this information from you.
Please let me know immediately and in writing if you require anything further from me. I appreciate your assistance with this matter.
* Although medical certification is not required unless your employer asks for it, to protect your rights fully,
include this sentence and attach the certification. You do not need to disclose a diagnosis to certify your need to take leave. To access the FMLA Medical Certification form WH-380 go to: esa/regs/compliance/whd/fmla/wh380.pdf
Sample FMLA Request Form #3 ? Reduced Schedule
TO: [Name of Director of Human Resources, Supervisor, or Other Manager]
FROM:
[Your name, Job Title]
RE: Notice of the Need for FMLA Leave
Date: [Today's Date]
This memo is to notify you of my need for a reduced schedule under the Family and
Medical Leave Act. It is medically necessary to change my schedule to
.
because of:
my own serious health condition.
caring for a family member (spouse, child, or parent) with a serious health condition.
I have attached a completed certification from a health care provider documenting my need for leave.*
It is my understanding that I am eligible for up to 12 weeks of leave per year under the Family Medical leave Act and that I will be reinstated to my job after my leave. [If you are covered by your employer's health insurance include this sentence, It is also my understanding that (Employer's Name) will continue my health insurance during my leave.]
The Family and Medical Leave Act specifies that employers must provide specific written notice to an employee of rights and responsibilities regarding leave within a few business days of when that employee gives notice of the need for leave (29 C.F.R. 825.301). I look forward to receiving this information from you.
Please let me know immediately and in writing if you require anything further from me. I appreciate your assistance with this matter.
* Although medical certification is not required unless your employer asks for it, to protect your rights fully, include this sentence and attach the certification. You do not need to disclose a diagnosis to certify your need to take leave. To access the FMLA Medical Certification form WH-380 go to:
esa/regs/compliance/whd/fmla/wh380.pdf ?
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- fmla form 5 family and medical leave act fmla certification of
- notice of eligibility rights and responsibilities u s dol
- sample fmla request forms
- 1 fmla training for managers final 11 03 15 iowa
- family and medical leave iowa
- certification of health care provider for u s department of labor
- designation notice u s department of labor under the family and dol
- fmla form 3 b family and medical leave act fmla new york city
- fmla form 3 a certification of health care provider for employee s
- 2015 form 1040 irs tax forms
Related searches
- sample document request form
- sample check request forms
- check request forms excel
- sample check request form
- employee fmla request form
- sample report request form
- sample data request form
- fmla request forms 2020
- sample telecommuting request form
- fmla certification forms in spanish
- blank request forms to print
- data request forms examples