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.
Arizona Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word;
Rich Text
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FAQ
FMLA leave is available to Arizona employees who need time off to: recuperate from a serious health condition. care for a family member with a serious health condition. bond with a new child.
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.
The FMLA allows an employee to take up to 12 weeks of unpaid leave in an FMLA year. The FMLA year may be the same as the calendar year, but does not have to be.
To be eligible for FMLA benefits, you must:Work for an employer to whom the FMLA applies.Have been employed by the employer for at least 12 months (one year)Have worked for at least 1,250 hours during the 12-month period right before the start of the leave.More items...
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
FMLA time off is unpaid. However, if the employer offers some paid time off, such as vacation pay, employers can require employees on FMLA to use this paid time off while on FMLA.
To be eligible for FMLA benefits, you must:Work for an employer to whom the FMLA applies.Have been employed by the employer for at least 12 months (one year)Have worked for at least 1,250 hours during the 12-month period right before the start of the leave.More items...
You can get up to 12 weeks of job-protected leave with continuous health insurance coverage. For the first two weeks, the employee will not receive pay, but for the remaining 10 weeks, the employee can receive pay at a rate of two-thirds the employee's regular rate of pay. Pay is capped at $200 per day, or $10,000.
You worked at least 1,250 hours (about 25 hours per week) in the past twelve months. The FMLA allows an employee to take up to 12 weeks of unpaid leave in an FMLA year. The FMLA year may be the same as the calendar year, but does not have to be. The employer determines the FMLA year.
Arizona families will face increased family and medical care needs. Paid leave means older adults and working people of all ages can get the support they need to receive and provide critical care.
