This form is an Employment Application. The form provides that applications are considered without regard to race, color, religion, or veteran status.
Employee Request Form For Fmla Leave In Fairfax
Category:
State:
Multi-State
County:
Fairfax
Control #:
US-00413
Format:
Word;
Rich Text
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FAQ
The Family and Medical Leave Act is administered by FMLASource. To initiate a claim or inquire about an existing claim, visit the FMLA website or call 877-GO2-FMLA (877-462-3652).
Virginia has no state equivalent of the federal Family and Medical Leave Act (FMLA). This Chart is intended for use by private employers. Local law may impose additional or different requirements. For information on the scope of local law coverage, see Local Law Coverage in Labor & Employment Resources.
Notify Your Employer: Notify your employer in writing or verbally of your need for FMLA leave. While immediate notice is not always possible, FMLA generally requires 30 days' advance notice. Submit Required Forms and Documentation: Complete any FMLA leave request forms provided by your employer.
FMLA is a federal law providing for an unpaid period of “protected absence” of up to 12 weeks, or up to 26 weeks for Military Caregiver Leave, in a twelve-month period for a qualifying event (see FMLA Fact Sheet for more qualifications).
An employer must permit the employee to take up to 2 weeks of leave for their own serious health condition in a calendar year, up to 2 weeks for the serious health condition of a parent, child or spouse, and up to 6 weeks for the birth or adoption of a child.
The FMLA Leave Process Step 1: You must notify your employer when you know you need leave. Step 2: Your employer must notify you whether you are eligible for FMLA leave within five business days. Step 3: Provide a completed certification to your employer.
Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave. Please let me know whether you approve this leave at your earliest convenience.
An employee may be required by the employer to submit a certification from a health care provider to support the need for FMLA leave to care for a covered family member with a serious health condition or for the employee's own serious health condition.
You are eligible if you meet these rules. You have worked for your employer for a total of 12 months. You have worked for your employer for at least 1,250 hours over the past 12 months. Your employer has at least 50 employees within 75 miles of where you work.