Utah Family and Medical Leave Request Form

State:
Multi-State
Control #:
US-266EM
Format:
Word; 
Rich Text
Instant download

Description

An employee may use this form to request leave under the FMLA.
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  • Preview Family and Medical Leave Request Form
  • Preview Family and Medical Leave Request Form
  • Preview Family and Medical Leave Request Form

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FAQ

To be eligible for FMLA you must have a qualifying event and have been employed with the State for 12 months and worked at least 1,250 hours in the 12 months immediately preceding the first day of the leave requested for FMLA.

Nine states (California, Colorado, Connecticut, Massachusetts, New Jersey, New York, Oregon, Rhode Island, and Washington) and the District of Columbia offer PFML. Of the states that have PFML policies currently on the books, six and D.C. are presently in effect. A PFML policy is scheduled to begin on Sept.

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.

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 FMLA only requires unpaid leave. However, the law permits an employee to elect, or the employer to require the employee, to use accrued paid vacation leave, paid sick or family leave for some or all of the FMLA leave period.

In addition to the federal Family and Medical Leave Act (FMLA), some states have their own comprehensive family leave laws that may also require employers to grant employees time off for the birth or adoption of a child or to care for a family member with a serious illness. However, Utah does not have such a law.

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

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

The FMLA gives eligible employees in Utah the right to take up to 12 weeks off work per year for pregnancy or parenting leave. The FMLA applies only to employers with at least 50 employees. If you qualify, you can use the FMLA to take time off when you are unable to work because of your pregnancy and childbirth.

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Utah Family and Medical Leave Request Form