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FMLA Employee Leave Request with Tip Sheet - ComplyRight Mobile App

Updated to comply with the most recent FMLA regulations effective March 8, 2013

Use this attorney-developed form to help collect important information necessary to determine whether an employee’s requested leave is covered by FMLA, without violating the FMLA and other privacy laws. Give the form to an employee as soon as he or she requests leave that may be FMLA-qualifying. Though not required by law, it is a good idea to distribute the form to ensure that the request is documented.

Need printed FMLA Forms? Visit G.Neil for a printed version of the

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Take a peek inside the FMLA Employee Leave Request with Tip Sheet - ComplyRight Mobile App

Included Features

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  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to 12 or...

  • Ico textbox

    Name

  • Ico textbox

    Employee ID #

  • Ico textbox

    Department

  • Ico textbox

    Job Title

  • Ico date

    Today's Date

  • Ico date

    Hire Date

  • Ico textbox

    Supervisor

  • Ico dropdown

    Status

  • Ico statictext

    I am requesting family/medical leave for the following reasons: (check all that apply)

  • Ico checkbox

    Birth of my child; to care for my newborn child

  • Ico checkbox

    Placement of a child with me for (Specified Reason) adoption (Specified Reason) foster care.

  • Ico dropdown

    Specified Reason

  • Ico checkbox

    Leave to care for a family member with a serious health condition

  • Ico textbox

    Relationship of family member to you:

  • Ico checkbox

    My own serious health condition

  • Ico checkbox

    Qualifying exigency because a family member is on or has been called to covered active duty in th...

  • Ico textbox

    Relationship of family member to you:

  • Ico checkbox

    Leave to care for a family member who is a current member of the Armed Forces (including the Nati...

  • Ico textbox

    Relationship of family member to you:

  • Ico checkbox

    Other

  • Ico multiline

    If Other, please specify:

  • Ico date

    Leave expected to begin

  • Ico date

    Leave expected to end

  • Ico multiline

    If intermittent or reduced-leave schedule is being requested, please explain why it is needed and...

  • Ico statictext

    I certify that the above information is true and correct to the best of my knowledge

  • Ico date

    Date

  • Ico signature

    Employee signature

  • ...and More!

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