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.
Pennsylvania 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
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 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
Who Qualifies for FMLA in PA?You have to have worked at least 1,250 hours in the past 12 months.You would have to work for about 24 hours a week for 52 weeks.If you took vacation time, that number goes up to about 26 hours a week.
Let our Pennsylvania FMLA Lawyers fight for you! Under the Family Medical Leave Act of 1993 (FMLA), you or your family member may be entitled to 12 weeks of time off. Learn more below about FMLA and what you or your family should do if it needs to be used.
You can call the United States Department of Labor's Wage-Hour toll-free information and help line at 1-866-4USWAGE (1-866-487-9243) or visit its website at for more information about the FMLA or filing a complaint with the Department of Labor.
Pennsylvania employers must comply with the FMLA if they have at least 50 employees for at least 20 weeks in the current or previous year. Employees may take 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.
You are protected by the FMLA if you meet the following requirements: (1) you work at a location where at least 50 employees are employed by your employer within 75 miles of that location; (2) you have worked for your employer for at least one year; and (3) you have worked at least 1,250 hours over the last twelve
Pennsylvania 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.
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.