This form is an application for Family and Medical Leave. It is to be filled out by an employee who is requesting a leave of absence.
Application Fmla Print For Chrome
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
Instant download
Description
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How to fill out Employee Application For FMLA?
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FAQ
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.
The Family and Medical Leave Act (FMLA) provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.
For CT Family and Medical Leave (i.e., to receive job protection for a leave), The employee must notify their employer of their need for leave and their employer will provide them with the notices and forms to fill out. The employee must complete the forms and return to their employer.
All covered employers are required to display and keep displayed a poster prepared by the U.S. Department of Labor summarizing the major provisions of the Family and Medical Leave Act (FMLA) and telling employees how to file a complaint.
Do I have to return to work to quit? FMLA does not require that you must return to your employment at the end of your leave of absence, or provide two weeks notice of not returning to the company. Unfortunately, you may be immediately terminated if you provide two weeks notice.