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Get NPMHU FMLA 2004-2024

only to the condition for which the employee is taking FMLA leave. This information is needed for the employee to receive job protection for leave due a serious health condition. PLEASE FILL OUT THE ENTIRE FORM. Employee Name (Print) 1. Patient's name: __________________________________ Relationship to employee: Self (omit question #6) Child Spouse Parent 2. Description of serious health condition: The back of this form describes what is meant by a “serious health condition” under FM.

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