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.
Georgia Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word;
Rich Text
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FAQ
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.
No. The FMLA only requires unpaid leave. However, the law allows an employee to elect or the employer to require the employee to use accrued paid leave, such as vacation or sick leave, for some or all of the FMLA leave period.
The Family Medical Leave Act (FMLA) entitles eligible employees to take up to 12 weeks of unpaid, job-protected leave each year. The employee must be employed for at least one year and have worked at least 1,250 hours during the previous 12 months.
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.
Georgia 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.
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.
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
Effective July 1, 2021, state government employees in Georgia enjoy paid parental leave benefits. House Bill (HB 146) provides 3 weeks of compensated time off for eligible workers when they have a birth, adopt a youngster, or foster a 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.
