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.
New Hampshire Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
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Word;
Rich Text
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FAQ
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.
Like employers in every state, New Hampshire employers must follow the federal Family and Medical Leave Act (FMLA), which allows eligible employees to take unpaid leave for certain reasons. Once an employee's FMLA leave is over, the employee has the right to be reinstated to his or her position.
Contact your Agency Human Resource representative as soon as you know you will be out due to a FMLA qualifying event. Human Resources will provide you with all the required forms needed to review your request. You will need to: Provide your agency Human Resources with certification of the need for leave.
What Are the State Plan Benefits? Eligible employees can receive: Up to six weeks a year with no minimum duration required. 60% of their average weekly wage, capped at the Social Security taxable wage maximum.
Though the FMLA itself is unpaid, it is sometimes possible under certain specific circumstances to use paid leave that you've accrued on the job as a way to get paid during your FMLA leave. The types of paid leave that might be considered include vacation days and sick days, as well as other types of paid leave.
In New Hampshire, employers are not required to provide employees with paid family or sick leave employees may be entitled to 12 weeks of job-protected family and medical leave under the federal Family and Medical Leave Act (FMLA), but that leave is unpaid.
Leave for Employees not Eligible Under FMLA New Hampshire law also entitles female employees to leave related to the birth of a child even if the FMLA does not require the employer to provide her with leave.
In New Hampshire, employees may take up to 12 weeks of leave in a 12-month period for a serious health condition, bonding with a new child, or qualifying exigencies. This leave is available every 12 months, as long as the employee continues to meet the eligibility requirements explained above.
To be eligible for FMLA leave, an employee must have worked for the employer for at least 12 months and for at least 1,250 hours within the 12-month period prior to the need for the FMLA leave.
