FMLA Acknowledgement Letter Template (to be given with ...



On School Letterhead

October 22, 201

Mr/Ms First Name Last Name

Address

City, State Zip

RE: FMLA Acknowledgement Letter & FMLA Medical Certification Request

Dear First Name ,

This is to advise that you may qualify for up to 12 weeks of job-protection under the Family & Medical Leave Act.

At this time we’re requesting that you complete the following | FMLA Leave forms and return to us within 15 days.

Leave of Absence Request.

FMLA Certification of Healthcare Provider. This form is required for any of the following:

▪ Birth of a child and to care for the employee’s newborn child.

▪ Placement of a child with the employee for adoption or foster care.

▪ To care for an immediate family member (spouse, child, or employee's parent) with a serious health condition.

▪ Employee’s own serious health condition.

Designation Notice

We will advise whether your leave is approved upon receipt of the Medical Certification form, as well as advise you on the timeframe for your leave’s expiration.

Disability Insurance Claim, if applicable

We are providing the instructions on initiating a Short Term Disability claim with our Guardian Insurance Carrier to help cover a percentage of your wages during the period while you are unable to work.

Any employee-paid insurance premiums are still due to the School/Parish/Agency during the period of FMLA leave.

Certificate to Return to Work

When you know of an expected return date, please contact me or our Finance Office Secretary with that date/and/or should the date change. On or before your first day back to work, you are required to submit documentation from your medical provider releasing you to full-duty based on the essential functions of your job in order to return to work. This is for your protection, as well as for our Parish/School.

If you have any questions about these forms or about your leave, please contact us at the main office phone number at (504) xxx-xxxx.

Sincerely,

Staff member name

Office Administrator

cc: Personnel File Attachments

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