Family and Medical Leave Forms

for Your State

Specifically designed to be used to comply with the Federal Family and Medical Leave Act.

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This form is to be used to comply with the Federal Family and Medical Leave Act which requires that eligible employees be entitled to up to 12 weeks of unpaid and job-protected leave for certain family and medical reasons.

This form is for use in all states.

Among others, this form includes the following provisions:
Eligibility
Reasons for requested leave
Number of Pages3
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#22089
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.






Family and Medical Leave Form










This Packet Includes:
1. Information
2. Family and Medical Leave Form





Information
Family and Medical Leave Form

This form is to be used to comply with the Federal Family and Medical Leave Act which requires that eligible employees be entitled to up to 12 weeks of unpaid and job-protected leave for certain family and medical reasons. To be eligible, an employee must meet the following conditions:

   Have worked for the company for a total of 12 months (does not need to be consecutive)
   Have worked for the company at least 1,250 hours in the last 12 months
   Have a serious health condition that makes him or her unable to perform his or her job, OR
   Have a child, spouse, or parent with a serious health condition that requires the employees full-time care, OR
   Have a child which after birth, adoption, or foster care requires full-time attention of the employee (whether employee is father or mother)







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Family and Medical Leave Form



Date of request _______________


Employee name  ___________________________________________
Social Security number  _________    Job title   ___________________
Department  _________________    Date hired   __________________


Under the Federal Family and Medical Leave Act (FMLA), eligible employees are entitled to up to 12 (twelve) weeks of unpaid, job-protected leave for certain family and medical reasons. Please submit this request form to your supervisor at leave 30 (thirty) days before the leave is to begin, if possible. When submission of this form 30 (thirty) days in advance is not possible, submit the request as early as possible. The employer reserves the right to deny or postpone leave for failure to give appropriate notice whenever such denial or postponement would be permitted under federal or state law.

Eligibility

Yes
No
1. Have you worked for the company for a total of
12 months or more (whether or not consecutively)?

___
___
2. During the past 12 months, have you worked at least 1,250 hours?

___
___
3. Have you previously received medical or family
leave? If yes, explain:
Dates of previous leave: From ______ to ______
Purpose of leave: ________________________
_______________________________________

___
___
4. Have you taken any intermittent leave?
If yes, explain: __________________________
______________________________________

___
___
5. Have you taken other time off from your scheduled
work? If yes, explain: _____________________
_______________________________________
___
___


Reasons for Requested Leave

___      Serious health condition that makes you unable to perform your job
Explain: _______________________________________________
______________________________________________________

___      Serious health condition of child, spouse, or parent
Explain: _______________________________________________
______________________________________________________

___      Care for child after birth, adoption, or foster care
Explain: _______________________________________________
______________________________________________________


Dates of requested leave: From: ____________ To:_____________


I agree to return to work on ____________________ . If any circumstances change and I am unable to return to work on that date, I agree to inform my employer immediately in writing. I understand that my benefits will continue during my leave and that I will arrange to pay my share of any benefit premiums.



__________________________         ________________________
Signature of Employee            Date


Approved   _________________
Denied   _________________



__________________________         ________________________
Signature of Employer            Date



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