FMLA Form Pa

response is required to obtain or retain the benefit of FMLA protections. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. If this is a request for leave to care for a family member or next of kin, do not use this form; obtain the correct form from your human resources office.

Complete this form to request an absence in accordance with the Family and Medical Leave Act (FMLA). Consult with your FMLA/SPF Coordinator to determine eligibility. Supporting documentation is required within 15 calendar days. FMLA/SPF absence cannot be used for approved work-related injuries. Referencethe . Notice to Employees . for

Forms, Letters & Notices. The following templates are provided for agency use. They may be customized to include agency-specific details, such as contact information for your HR office. However, agencies should NOT make changes to the wording of the documents themselves. Any questions regarding customization of templates should be directed to …

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 employee’s own …

FMLA & SPF Absences. FMLA/SPF Absence is a paid or unpaid absence from work with benefits due to the serious health condition of an employee, the serious health condition of a qualifying family member when the employee is attending to the medical needs of the family member, or for the birth, adoption or foster care placement of a child.