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.
Indiana Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word;
Rich Text
Instant download
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How to fill out Employee Application For FMLA?
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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.
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.
In addition to the federal Family and Medical Leave Act (FMLA), some states have their own comprehensive family leave laws that may also require employers to grant employees time off for the birth or adoption of a child or to care for a family member with a serious illness. However, Indiana does not have such a law.
CAN YOU COLLECT UNEMPLOYMENT BENEFITS WHILE ON FMLA LEAVE? Generally no, you are not eligible for unemployment benefits if you take medical leave under the Family and Medical Leave Act and you cannot work.
The FMLA only requires unpaid leave. However, the law permits an employee to elect, or the employer to require the employee, to use accrued paid vacation leave, paid sick or family leave for some or all of the FMLA leave period.
To be eligible for family medical leave employees must have:Have worked at least 1,250 hours in the 12-month period immediately preceding the need for family-medical leave. Have not exhausted their allotment of family-medical leave in the applicable time period.
When am I eligible for time off under the FMLA? You must have worked for your employer for at least 12 months and you must have worked for at least 1,250 hours during the last year. The employer must have at least 50 or more employees within 75 miles of where you work.
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.
FMLA leave is unpaid, but employees may be allowed (or required) to use their accrued paid leave during FMLA leave.
