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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 FMLA allows an employer to require that the employee submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to the serious health condition of the employee.
Employer Instructions and Forms When you become aware of an employee’s need for family or medical leave* complete the following: Provide the employee with a Request for Family/Medical Leave under the FMLA form.
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.
This is a sample form for employees to request time off under the Family and Medical Leave Act.
FAMILY AND MEDICAL LEAVE ACT (FMLA) (SEE 3 FAM 3530) U.S. Department of State c. The care of a spouse, son, daughter, or parent of the employee with a serious health condition. b. The placement of a son or daughter with the employee for adoption or foster care and the care of such son or daughter. a.
The Family and Medical Leave Act (FMLA) lets eligible employees take unpaid leave for medical or family reasons. Learn about benefits, requirements, and how to report violations.
In general, to be eligible to take leave under the Family and Medical Leave Act (FMLA), an employee must have worked for an employer for at least 12 months, meet the hours of service requirement in the 12 months preceding the leave, and work at a site with at least 50 employees within 75 miles.
Download forms › IRS forms › Select material to view. MK-1247: Family & Medical Leave Act (FMLA) HR Handbook: Solutions for. Employees and families ; Employers
FMLA. Certification of Serious Health Condition Form – Pages 1 & 2 . Who should use this form? The information on the Certification of Serious Health Condition Form is required when applying for: • Medical leave due to your own serious health condition. • Medical leave due to your own pregnancy/child’s birth.