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.
Arkansas Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word;
Rich Text
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FAQ
Doctors aren't the only health care providers who may certify FMLA leave. Podiatrists, dentists, clinical psychologists, optometrists and chiropractors can all certify leave, as can nurse practitioners, nurse-midwives, clinical social workers and physician assistants.
In order to be eligible to take leave under the FMLA, an employee must (1) work for a covered employer, (2) work 1,250 hours during the 12 months prior to the start of leave, (3) work at a location where 50 or more employees work at that location or within 75 miles of it, and (4) have worked for the employer for 12
Employees are eligible to take FMLA leave if they have worked for their employer for at least 12 months, and have worked for at least 1,250 hours over the previous 12 months, and work at a location where at least 50 employees are employed by the employer within 75 miles.
To apply for FMLA, the employee must take an FMLA Medical Certification Form to their health care provider. This form ensures that the employee's or family member's applicable health condition is valid. After receiving the form, the employee must return it within 15 calendar days.
Key TakeawaysNine states (California, Colorado, Connecticut, Massachusetts, New Jersey, New York, Oregon, Rhode Island, and Washington) and the District of Columbia offer PFML.Of the states that have PFML policies currently on the books, six and D.C. are presently in effect.More items...
An eligible employee may receive up to four weeks of consecutive paid leave within the first 12 weeks after the birth of the employee's biological child OR the placement of an adoptive child in the employee's home. Arkansas is one of at least 10 states to have adopted paid leave policies for state employees.
How to File a Paid Family Leave (PFL) Claim by MailVisit Online Forms and Publications and order a form online. A form will be mailed to you.Obtain the form from your physician/practitioner or employer.Visit an SDI Office.Call 1-877-238-4373. California Relay Service (711) Provide the PFL number (1-877-238-4373)16-Feb-2022
EligibilityHave worked for your employer for at least 12 months; and.Have worked for your employer for at least 1,250 hours in the 12 months before you are taking leave; and.Work at a location where your employer has at least 50 employees within 75 miles of your worksite.
