Intermittent Family Medical Leave Tracking
Employee Name: _____________________________ Department:____________________________________
Supervisor Name: _______________________________
FML Time approved: From:___________________
To:______________________________
Intermittent Family Medical Leave Tracking
Use this worksheet to assist you in tracking both exempt and non-exempt employees' intermittent usage of Family & Medical Leave (FML) .
Under FML, an employee is eligible for up to twelve workweeks (for example, 480 hours at 100% time or 240 hours at 50% time) in a calendar year period provided that the employee has:
? At least 12 months cumulative University service ? Worked at least 1250 hours in the 12 months immediately preceding the commencement of the
leave. ? Not utilized his/her 12 weeks within the current calendar year.
Definitions
? Date
Enter the date for which FML is being applied
? Start Time Enter the time the employee leaves work. If employee is out for the entire day, enter start time of employee's shift.
? End Time Enter the time the employee returns to work. If employee is out for remainder of the day, enter end time of the employee's shift.
? Hours
Enter total time employee is out for each day.
? Call-in
Indicate if the employee notified you by calling on the day they wanted to use the time.
? Scheduled Indicate if the employee scheduled this time off in advance.
? Comment Note any relevant information.
Date
Start Time
End Time Hours Call-In
Scheduled Comments
Intermittent Family Medical Leaving Tracking
1
Employee Name: _____________________________ Department:____________________________________
Supervisor Name: _______________________________
FML Time approved: From:___________________
To:______________________________
Date
Start Time
End Time Hours Call-In
Scheduled Comments
Intermittent Family Medical Leaving Tracking
2
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