The Family and Medical Leave Act permits [Company name] to make periodic inquiries regarding any changes in your status and your intent to return to work upon completion of your leave. Accordingly, please complete this form and return it to the HR department, to the attention of [contact person's name], on or before [date].
Employee name: ________________________
Department: ____________________________
Date leave began: ________________________
Reason for leave: ___________________________________________
__________________________________________________________
Select one of the following. Please provide any information relevant to your selection.
- I reaffirm my intention to return to work on _______________; or
- You are hereby advised that I no longer intend to return to work on my scheduled return-to-work date for the following reason:
- I request a new return-to-work date of _______________________; or
- I do not intend to return to work.
Employee signature: ______________________________
Date: __________________________________________
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