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.
Nassau New York Employee Application for FMLA
State:
Multi-State
County:
Nassau
Control #:
US-AHI-200
Format:
Word
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Description
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How to fill out Employee Application For FMLA?
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FAQ
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.
FMLA Form WH-380-F for Family Health Condition You'll need to provide your family member's name and your relationship to that family member (only certain relatives qualify). You'll also need to describe the type of care you must provide and how much time off you will need.
When requesting a formal leave of absence, your letter should include: Request for a leave of absence, The dates you expect to be away from work, The date you plan to return to work, An offer to provide assistance, if feasible, Thanks for considering your request.
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
Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles.
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.
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 request PFL, the employee requesting PFL must complete Part A of the Request For Paid Family Leave (Form PFL-1). All items on the form are required unless noted as optional. The employee then provides the form to the employer to complete Part B.
Though the FMLA itself is unpaid, it is sometimes possible under certain specific circumstances to use paid leave that you've accrued on the job as a way to get paid during your FMLA leave. The types of paid leave that might be considered include vacation days and sick days, as well as other types of paid leave.
To apply for leave under FMLA, contact the personnel office of your employer agency. If eligible and approved, the personnel office will provide to the Fund's administrative office the appropriate information for continuation of Fund benefits.