FMLA Form Va Hospital

Request for FMLA, Child Care and Military Leave . SECTION 1. Tell us about you. Please, print all information legibly. 1. Print Employee Full Name (First Middle Last) 2. Employee ID 3. Date of Request 4. Employee Home Address (Number and street name; Apt No.; City; State) 5. Employee Home/Cell Phone No. 6. Alternate Phone 7. Personal Email Address. SECTION 2. Tell us …

form to Human Resources before my leave commences. I understand that if my leave is approved, my time away from work will be charged against my 12 week leave maximum under FMLA. Upon approval of this requested leave, I am required to utilize all paid time available to me prior to going into an unpaid leave status. In the event that I go into an unpaid status while on …

FMLA LEAVE REQUEST FORM . Part A: To be completed by employee and/or supervisor, and then submitted to supervisor. Employee Name _____Title/Agency/Unit _____ REASON FOR LEAVE: Birth of a child, or adoption of a child or placement of a child in foster care Due to the employee’s own serious health condition To care for a qualifying family member with a serious …

Health Condition” form (U.S. Department of Labor Form WH-380-E) to satisfy the certification requirement. Note: VSDP claim approval documentation shall be accepted for FMLA purposes. When leave is for a family member’s serious health condition, the health care provider should complete the "Certification of Health Care Provider for Family Member’s Serious Health …

While use of this form is optional, this form asks the health care provider for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R . § 825.306. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Additionally, you