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FMLA Company Response (Designation) 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 satisfy government requirements by providing employees the FMLA-related information they need after an FMLA request is made. The form notifies employees whether their leave will be designated and counted as FMLA leave. It should be used as soon as an employer has enough information to determine whether an employee’s leave is being taken for an FMLA-qualifying reason (e.g., after receiving a certification). The form should be completed and provided to employees within five business days from the time an employer acquires enough information to determine whether the employee’s leave is being taken for an FMLA-qualifying reason. Click here for a free tip sheet that includes guidelines to ensure accurate completion of the form, relevant FMLA definitions, and helpful do’s and don’ts. There are two Company Response forms that employers are required to provide to employees so employers should also see our FMLA Company Response (Eligibility) and Tip Sheet.

Need printed FMLA Forms? Visit G.Neil for a printed version of the FMLA Company Response (Designation) Form.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the FMLA Company Response (Designation) with Tip Sheet - ComplyRight Mobile App

Included Features

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Included Fields

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

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    Company Response (Designation) (Designation Notice)

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    Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected,...

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    To: (Employee)

  • Ico date

    Date

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    We have reviewed your request for leave under the FMLA and any supporting documentation you have ...

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    We received your most recent information on (Receiving Date) and decided:

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    Receiving Date

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    Your FMLA leave request is approved.

  • Ico checkbox

    Provided there is no deviation from your anticipated leave schedule, the following number of hour...

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    Specify number of hours, days or weeks:

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    Because the leave you will need will be unscheduled, it is not possible to provide the hours, day...

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    Please be advised (check if applicable):

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    You have requested to use paid leave during your FMLA leave.

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    We are requiring you to substitute or use paid leave during your FMLA leave.

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    You will be required to present a fitness-for-duty certificate to be restored to employment.

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    Is/Is not

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    Additional information is needed to determine whether your FMLA leave request can be approved:

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    The certification you have provided is not complete and sufficient to determine whether the FMLA ...

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    (Specify information needed to make the certification complete and sufficient.

  • Ico checkbox

    We are exercising our right to have you obtain a second or third opinion medical certification at...

  • Ico checkbox

    Your FMLA Leave request is Not Approved.

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    The FMLA does not apply to your leave request.

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    You have exhausted your FMLA leave entitlement in the applicable 12-month period.

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    It is mandatory for employers to inform employees in writing whether leave requested under the F...

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    This product is designed to provide accurate and authoritative information.

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    Important note: This is approved for use by the purchaser only.

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