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The Department has developed optional-use forms which can be used by employers to provide required notices to employees, and by employees to provide certification of their need for leave for an FMLA qualifying reason. These forms are electronically fillable PDFs and can be saved electronically.
The Family and Medical Leave Act (FMLA) provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.
The FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave.
Agencies may use the forms developed by DOL (see links below) or may create their own FMLA medical certification forms. In any case, agencies may only request the information specified in OPM’s regulations.
To request leave on the basis of the Family and Medical Leave of Act (FMLA), please complete the following request form and submit to Human Resources at least 30 days prior to leave...
Contact your supervisor and/or your personnel office to obtain additional information about your entitlements and responsibilities under the Family and Medical Leave Act. Medical certification of a serious health condition may be required by your agency.
Employee Request for FMLA Leave: You will need to complete this form and return it to us as soon as possible. A return envelope is enclosed. Certification of Health Care Provider: You will need...
☐ Obtain FMLA forms from the U.S. Department of Labor or create similar internal forms. ☐ Determine whether an employee's request for leave is for one of the following FMLA-qualifying reasons:...
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to 12 or 26 weeks of job-protected leave for certain family and medical reasons. Submit this request form to your human resources manager at least 30 days before the leave is to begin, when possible.
Step 1: You must notify your employer when you know you need leave. Step 2: Your employer must notify you whether you are eligible for FMLA leave within five business days. If their notification indicates that you are not eligible, then your leave is not FMLA-protected. (You may request leave again in the future. Employee eligibility can change.)