SAMPLE INITIAL CHECKLIST Please complete a copy of this form for each FMLA/VPFL-qualifying leave. Employee name: _______________________________________________________ Request is for:   □  Employee □  To care for a family member If the request is for a family member, state relationship: _______________________  Check all true statements: □ The employee has been employed by the employer for at least 12 months. □ The employee has worked at least 1,250 hours (FMLA) or an average of 30 hours per week in the 12-month period immediately preceding the date of leave. □ The employee has requested […]