Checklist: Individual FMLA Leave Request

Employee name: __________________________________________________________

Date of leave request: ______________________________________________________

Dates of anticipated leave: ___________________________________________________

☐ Obtain FMLA forms from the U.S. Department of Labor or create similar internal forms.

☐ Determine whether an employee's request for leave is for one of the following FMLA-qualifying reasons:

☐ The birth of a son or daughter and to care for the newborn child.

☐ Placement with the employee of a son or daughter for adoption or foster care.

☐ To care for the employee's spouse, son, daughter or parent with a serious health condition.

☐ A serious health condition of the employee that makes the employee unable to perform the functions of his or her job.

☐ A covered family member's active duty or call to active duty in the National Guard or Reserves in support of a contingency operation.

☐ To care for an injured or ill covered service member.

☐ Within five days of learning of an employee's need for leave that may be FMLA-qualifying, provide the employee with the Notice of Eligibility and Rights & Responsibilities form (WH-381).

               Date notice provided: ______________________

☐ Determine whether the employee is eligible for FMLA leave. An eligible employee is an employee of a covered employer who:

☐ Has been employed by the employer for at least 12 months.

☐ Has worked at least 1,250 hours (actual hours worked) during the 12-month period immediately preceding the start of the FMLA leave.

☐ Is employed at a worksite where 50 or more employees are employed by the employer within 75 miles of that worksite.

☐ Determine whether the employee has used FMLA leave previously and calculate how much FMLA leave the employee has available. An eligible employee is entitled to take up to 12 weeks of FMLA leave during a 12-month period (26 weeks to care for an injured or ill covered service member). The employer's FMLA policy should specifically state which one of the following methods it uses to calculate the 12-month period.

The options are:

• The calendar year.
• Any fixed 12-month period, such as a fiscal year or a year starting with the employee's anniversary date.
• The 12-month period as measured forward from the date the employee's FMLA leave first begins.
• A "rolling" 12-month period measured backward from the date an employee uses any FMLA leave.

Has the employee used FMLA leave in the 12-month period as described in the employers FMLA policy? __ Yes __ No

If yes, amount of leave remaining: ______________

Expected duration of leave: ____________________

☐ Determine whether a medical certification is necessary and inform the employee if a medical certification is required. If no medical certification is required (e.g., the birth of a child), complete and provide to the employee the Designation Notice (WH-382) within five days of learning of the need for leave.

        Date notice provided: ________________________

☐ If required, provide the employee with the appropriate certification form (one of the following):

• Certification of Health Care Provider for Employee's Serious Health Condition (DOL Form WH-380-E).
• Certification of Health Care Provider for Family Member's Serious Health Condition (DOL Form WH-380-F).
• Certification of Qualifying Exigency for Military Family Leave (DOL Form WH-384).
• Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave (DOL Form WH-385).
• Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (DOL Form WH-385-V).

☐ Provide the employee with at least 15 calendar days to return the certification form.

        Date certification form due: _________________

        Date certification form returned: _____________

☐ Review the received certification form to ensure that it is complete and sufficient. If information is missing or needs clarification, return the form to the employee with details regarding the information that is needed from the health care provider. Allow the employee at least seven days to return the revised certification form.

Describe any efforts to validate the medical certification:  _____________________________________________________________________

☐ Within five business days after the employee submits a complete and sufficient certification form, provide the employee with the Designation Notice (WH-382).

        Date notice provided: ________________________

DURING LEAVE

☐ Maintain the employee's coverage under any group health plan at the same level and under the same conditions as would be maintained had the employee continued actively working, including employer contributions.

☐ Collect premium payments for health insurance from the employee during periods of unpaid FMLA leave.

☐ Review internal policies to determine how other benefits are impacted by an FMLA absence, such as paid-time-off accruals, life insurance, etc.

☐ Ensure that the employee complies with any requirement for periodic updates to the employer during leave.

RETURN TO WORK

☐ Have the employee obtain a release to work from his or her health care provider, if required.

☐ Reinstate the employee to the same or an equivalent position.

☐ Arrange for the repayment of outstanding insurance premiums owed by the employee.

☐ Maintain records of the employee's FMLA leave for a minimum of three years, separate from the employee's personnel file.