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.
Texas Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word;
Rich Text
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FAQ
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.
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
To be eligible, an employee has to have worked at least 1250 hours within the last 12 months; has to have worked at least 12 months' total time for the employer; and be employed at a facility at which at least 50 employees are employed within a 75-mile radius - due to the 1250-hour requirement, many part-time employees
The first two weeks (10 days) of leave are unpaid, but an employee may use accrued paid leave, including the new emergency sick leave during this time. The remaining 10 weeks are paid at two-thirds the employee's regular rate for a maximum payment of $200 per day ($10,000 total).
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.
An employee is eligible to take leave through FMLA if you meet the following conditions: you have worked for your company for at least one year. you worked at least 1,250 hours last year (an average of about 25 hours per week) you work for a company that is not exempt from FMLA regulations.
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.
The employer must determine whether the medical condition meets the FMLA definition of a serious medical condition; and whether the certification articulates the necessary information for FMLA leave. If the certification meets the FMLA requirements (and the employee is eligible) then you cannot be denied FMLA leave.
