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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.
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider.
Request for Family/Medical Leave Under the FMLA. In order to be eligible for up to 12 weeks (or 26 weeks for Military Caregiver Leave) of unpaid leave (in a 12-month period) under the Federal Family and Medical Leave Act (FMLA)*, the following criteria must be met:
I invoke the FMLA for the following reasons. (check one of the following) The birth of a son or daughter of the employee and the care of such son or daughter. The placement of a son or daughter with the employee for adoption or foster care and the care of such son or daughter.
Please click on the link below to be directed to the U.S. Department of Labor – Wage and Hour Division website for the following FMLA certification forms: WH-380-E Certification of Health Care...
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.
Please complete Section I before giving this form to your medical provider. The FMLA permits an employer2 to require that you submit a timely, complete, and sufficient medical certification to support your request for FMLA leave due to your own serious health condition.
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.
To fill out a Family Medical Leave Act form, start by downloading the form that fits your circumstances from the FMLA website. Next, ask your employer to fill out Section 1, which asks for your job description, work schedule, and job functions.