Family Medical Leave
FMLA Leave Request Form
This form is used by an employee to formally request family or medical leave.
This form is used by an employee to formally request family or medical leave.
WH381-Notice of Eligibility and Rights and Responsibilities form
to inform employees of their rights and responsibilities. It is to be provided to employees within five days of learning of the need for leave.
to inform employees of their rights and responsibilities. It is to be provided to employees within five days of learning of the need for leave.
WH380E-Certification of Health Care Provider form for Employee’s Serious Health Condition
employee must have his or her health care provider certify the employee's own serious health condition. The employee is to have at least 15 days to return this.
employee must have his or her health care provider certify the employee's own serious health condition. The employee is to have at least 15 days to return this.
WH380F-Certification of Health Care Provider form for Family Member’s Serious Health Condition
employee to have his or her family member's health care provider certify the family member's serious health condition. The employee is to have at least 15 days to return this.
employee to have his or her family member's health care provider certify the family member's serious health condition. The employee is to have at least 15 days to return this.
WH384-Certification of Qualifying Exigency for Military Family Leave)
employee to support the need for qualifying exigency because of active duty (Reserves, National Guard, Retired) leave certified. The employee is to have at least 15 days to return this.
employee to support the need for qualifying exigency because of active duty (Reserves, National Guard, Retired) leave certified. The employee is to have at least 15 days to return this.
WH385-Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave
employee to support the need for leave to care for a family member who was seriously injured or made ill in the line of military duty. The employee is to have at least 15 days to return this.
employee to support the need for leave to care for a family member who was seriously injured or made ill in the line of military duty. The employee is to have at least 15 days to return this.
WH385V-Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave
employee to support the need for leave to care for a family member who is a veteran who was seriously injured or made ill in the line of military duty. The employee is to have at least 15 days to return this.
employee to support the need for leave to care for a family member who is a veteran who was seriously injured or made ill in the line of military duty. The employee is to have at least 15 days to return this.
WH382-Designation Notice
Provide this to employees within five days of making this determination. If you are going to require a fitness-for-duty certification, this requirement must be included.
Provide this to employees within five days of making this determination. If you are going to require a fitness-for-duty certification, this requirement must be included.
FMLA Fitness for Duty Form
to obtain certification from a health care provider that an employee is able to resume work.
to obtain certification from a health care provider that an employee is able to resume work.
FMLA HIPAA Authorization Form
These authorizations are an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information that is described in the authorization for the purpose(s), and to the recipient(s) stated in the authorization.
These authorizations are an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information that is described in the authorization for the purpose(s), and to the recipient(s) stated in the authorization.
FMLA Declaration of Relationship
This form should be completed by the employee when the employee requests Family and Medical Leave.
This form should be completed by the employee when the employee requests Family and Medical Leave.