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.
Minnesota Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word;
Rich Text
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FAQ
Employees are eligible for FMLA leave if: they have worked for the company for at least a year. they worked at least 1,250 hours during the previous year, and. they work at a location with at least 50 employees within a 75-mile radius.
If you are not eligible for FMLA, you may still be eligible for a Medical Leave under Civil Service Rules or your collective bargaining agreement.
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
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.
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.Have worked for at least 1,250 hours during the 12-month period right before the start of the leave.More items...
Eligibility - all working Minnesotans, including small business owners & those self-employed are eligible for up to 12 weeks of medical leave & up to 12 weeks of family leave.
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.
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
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.
