Family And Medical Leave Act Checklist

Please complete a copy of this form for each FMLA-qualifying leave of more than (3) days or each FMLA qualifying leave.

Employee name:  ______________________________________ Date: _____/_____/_____

                                                    Please print

Leave 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 for at least 12 months (does not have to be consecutive)

 The employee has worked at least 1,250 hours in the 12-month period immediately preceding the date of leave.

 The employee works in a position that requires at least 1,250 hours in a 12 month period

 The employee or family member has seen a health care provider (in the case of a serious health condition).

 A medical certificate has been supplied by the employee.

 The employee has been verbally and in writing told that the leave is to be counted as FMLA qualifying.

 The leave is  for intermittent or reduced schedule leave.

 Take leave for periods of a particular duration, not to exceed the planned medical treatment; or

 Transfer temporarily to an available alternative position of equivalent pay and benefits in order to better accommodate recurring periods of leave.