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.
Utah Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
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.
When an employee requests FMLA to care for a family member with a serious health condition, the same documents are mailed to the employee -- leave of absence request form, certification for the doctor to complete and the official notice that contains the rights and responsibilities of the employee and the employer.
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.
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.
I am writing to inform you that I will be taking a sick leave because of a serious infection in my throat. I will be absent from work until October 14. I have attached a note from my doctor to confirm that it is necessary for my health and the health of my coworkers for me to take a medical leave.
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.
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 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.
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.
