Family and Medical Leave Act and Vermont Parental Leave Act

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 leave; the employee has called in sick three days; or the employer is otherwise aware that an employee’s absences may be for an FMLA/VPFL qualifying reason.

□ The employer has provided the employee with the FMLA Notice of Eligibility and Rights & Responsibilities.

□ The employer has requested the employee to provide medical certification for qualifying leave based on serious health condition of employee or family member.

□ The employee has provided medical certification for qualifying leave based on serious health condition of employee or family member. 

□ The employer has provided the employee with the FMLA Designation Notice.