FMLA.form

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. OMB Control Number: 1235-0003 . RETURN TO THE PATIENT. Expires: 6/30/2023 . The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave to care for a family member with a serious health condition to submit a medical certification …

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 …

The Department of Labor (DOL) Wage and Hour Division enforces the Family and Medical Leave Act (FMLA), which provides workplace protections – unpaid, job protected leave – to those living with a serious health condition, including HIV/AIDS. Determine your eligibility for this benefit

WH-385 Form & Instruction; WH-385V: FMLA Certification for Serious Injury or Illness of a Veteran for Wage and Hour Division Military Caregiver Leave. WH-385V Form & Instruction; WH-501: MSPA Wage Statement. WH-501 (PDF) WH-501 Spanish (PDF) WH-514: MSPA Vehicle Mechanical Inspection Report for Transportation Subject to Department of Transportation …

After the completed Request for Family/Medical Leave under the FMLA form has been received and reviewed, complete the Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act) WH-381 form and the Designation Notice (Family and Medical Leave Act) WH-382 form, and give to the employee via hand delivery or certified mail. If leave is due to the …

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 …

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