Family Medical Leave

The Family and Medical Leave Act of 1993 (FMLA) gives certain job protections to employees when balancing work responsibilities with the demands of personal illness or injury or in caring for family members.

Employee rights under the Family Medical Leave Act.

Eligibility, rights, and responsibilities under the Family Medical Leave Act.

This form is used by an employee to formally request family or medical leave.

This form is to inform employees of their rights and responsibilities. It is to be provided to employees within five days of learning of the need for leave.

Employee must have his or her healthcare provider certify the employee’s own serious health condition. The employee is to have at least 15 days to return this.

Employee to have his or her family member’s health care provider certify the family member’s serious health condition. The employee is to have at least 15 days to return this.

Employee to support the need for qualifying exigency because of active duty (Reserves, National Guard, Retired) leave certified. The employee is to have at least 15 days to return this.

Employee to support the need for leave to care for a family member who was seriously injured or made ill in the line of military duty. The employee is to have at least 15 days to return this.

Employee to support the need for leave to care for a family member who is a veteran who was seriously injured or made ill in the line of military duty. The employee is to have at least 15 days to return this.

Provide this to employees within five days of making this determination. If you are going to require a fitness-for-duty certification, this requirement must be included.

To obtain certification from a health care provider that an employee is able to resume work.

These authorizations are an individual’s signed permission to allow a covered entity to use or disclose the individual’s protected health information that is described in the authorization for the purpose(s), and to the recipient(s) stated in the authorization.

This form should be completed by the employee when the employee requests Family and Medical Leave.