FMLA Forms Michigan

Disability Management Office Forms. Leave of Absence (LOA) CS1808: Certification or Qualifying Exigency for Military Family Leave. CS1809: Injury or Illness of Covered Service Member. CS1835: Non-FMLA Medical Certification by Physician. CS1837: Medical Certification of Employee’s Serious Health Condition. CS1838: Application for Leave of Absence.

Mileage Reimbursement Form Employees requesting reimbursement for mileage associated with medical treatment necessary for a work-related injury or illness may use this form. The Mileage Reimbursement Form can be completed and submitted entirely online. If you prefer, print the form and send it to Work Connections via email, fax, or U.S. Mail.

FMLA Certification Forms: Employee Own Health Family Member Current Service Member for Military Veteran or Military Caregiver FMLA Time Tracking Bank (effective May 1, 2021) Effective May 1 for monthly and May 2 for bi-weekly, all Michigan Medicine departments will be required to open an FMLA case with the Human Resources Solutions Center (HRSC).

CS-1810 State of Michigan . Rev 7/2019 . Leave of Absence Application For FMLA, Medical (Including Extended Use of Leave Credits), and Parental Leaves Only. Contact your HR Office for the appropriate form for other leaves of absence . Employee completes Section I (Page 1) ONLY: Sections II and III are completed by the HR Office . Employee Information. Employee’s Name …

CS1843: Non-FMLA Medical Certification by Physician. CS1844: Medical Certification of Employee’s Serious Health Condition. CS1845: Application for Leave of Absence. CS1840: Family Member’s Serious Health Condition. Workers’ Compensation (WC) State of Michigan Workers’ Compensation Claim Form.

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206 E. Michigan Ave., P.O. Box 30003, Lansing, MI 48909 or fax to 517241- -6898. 1. Employee Full Name: 2. Employee ID #: 3. Employee Job Title: 4. Employee Regular Work Schedule: 5. Employee’s Essential Job Functions (also refer to any attached job description): SECTION II – For completion by health care provider. The employee listed above has requested leave under the …

Spouses employed by the State of Michigan are jointly entitled to a combined total of 12 workweeks of FMLA leave for the birth of a child, placement of a child for adoption or foster care, or care for a parent who has a serious health condition. Each employee is not entitled to a separate 12- week FMLA leave for these purposes.