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.
Nebraska Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
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.
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.
Under the FMLA, a serious health condition is an illness, injury, impairment or physical or mental condition that involves inpatient care (defined as an overnight stay in a hospital, hospice or residential medical care facility; any overnight admission to such facilities is an automatic trigger for FMLA eligibility) or
FMLA leave is unpaid, and Nebraska does not have a paid family leave law or offer paid short-term disability benefits. However, you may askor your employer may require youto use your accrued paid leave (like sick days, vacation, or PTO) to get paid during your time off.
In order for an employee to be eligible to take FMLA leave due to stress, the stress must be so severe that it amounts to a serious health condition which renders the employee unable to perform the tasks required by his or her job.
Employees are eligible for FMLA leave if they: have worked for the employer for at least a year. have worked at least 1,250 hours during the 12 months prior to taking leave, and. work at a location where the employer has at least 50 employees within a 75-mile radius.
FMLA leave is unpaid, and Nebraska does not have a paid family leave law or offer paid short-term disability benefits. However, you may askor your employer may require youto use your accrued paid leave (like sick days, vacation, or PTO) to get paid during your time off.
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.