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.
Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
Instant download
Description
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How to fill out Employee Application For FMLA?
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FAQ
How Do I Request FMLA Leave? To take FMLA leave, you must provide your employer with appropriate notice. If you know in advance that you will need FMLA leave (for example, if you are planning to have surgery or you are pregnant), you must give your employer at least 30 days advance notice.
Dear (Supervisor / HR Manager): Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave.
Step 1: Determine eligibility. There are two questions that need to be answered here. Step 2: Establish the qualifying reason. Step 3: Provide eligibility notice. Step 4: Provide request for medical certification. Step 5: Provide designation notice. Step 6: Leave is taken. Step 7: Return to work and reinstatement.
Dear name, I am writing this letter to inform you that I need to take sick leave from work. I will need to remain off work until date. I've included a letter from my doctor to confirm that I need to take that amount of time off to fully recover.
Understand your legal rights regarding time off and pay. Make the request in person. Give sufficient advance notice. If possible, work with your boss to develop an agreeable plan. Keep track of relevant paperwork.
The FMLA permits employers to request a doctor's note or medical certification when an employee first requests leave under the FMLA. If the employee is on extended leave, a doctor's note can be requested every 30 days.
Work for a covered employer; have worked 1,250 hours during the 12 months prior to the start of leave; ( special hours of service rules apply to airline flight crew members )
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
If you are providing care for a family member and completing form WH-380-F, you will be required to take the FMLA form to your family member's health-care provider. Your healthcare provider is required by law to provide only factual information on this form.