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.
Wisconsin 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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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.
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.
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
Employee has at least 1000 hours of work and paid leave for employer in the preceding 52 weeks and employee worked for employer for at least 52 consecutive weeks. 12 weeks during a 12 month period. Leave for birth, adoption, or to care for sick parent or childmust be shared by spouses working for same employer.
Covered employers must allow up to six (6) weeks of family leave in a 12-month period for: The birth of an employee's natural child, if the leave begins within 16 weeks of the child's birth.
Employees are entitled to continue their health insurance while on leave, at the same cost they must pay while working. FMLA leave is unpaid, but employees may be allowed (or required) to use their accrued paid leave during FMLA leave.
Main Differences between Wisconsin FMLA and Federal FMLAWisconsin's FMLA requires that that the employee worked for the employer the preceding 52 weeks and only requires 1,000 hours of work. FMLA allows up to 12 weeks of leave to be taken, while WFMLA allowed up to 8 weeks of leave, but under more generous reasons.
Go to the Employee information page found on the Wisconsin dot.gov home page. Then find the FMLA Request section and click on Access FMLA Request Application link. The electronic FMLA Leave Request form should be submitted by the employee, whenever medically able.
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.