Skip redundant pieces
 

Family and Medical Leave Act Departmental Checklist

Please complete this form for each FMLA-qualifying leave of more than (3) days or each FMLA-qualifying leave due to a chronic condition.

Employee Information
   

Request is for: Employee Family Member

Note: Eligible family members are the spouse, parent, natural/adopted/legal custody child who is under age 18 or, if older, must be incapable of self-support due to physical or mental impairment.


Sun. Mon. Tues. Wed. Thurs. Fri. Sat.





Yes No     Has the employee been employed by the state for at least 12 months?

Yes No     Has the employee worked for the state at least 1,250 hours in the 12 month period immediately preceding the date of leave?

Yes No     Has the employee or family member seen a health care provider?

Yes No     If a medical certificate is required, has it been supplied by the employee?

Yes No     Has the employee been verbally told that the illness is to be counted as FMLA-qualifying?

Yes No     Has the employee disputed this designation?


 

Contact Information


   



 

 

     Last modified: May 01, 2012