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Fmla request Form: What You Should Know

If the worker is unable to meet the FMLA leave entitlement requirement, an alternate¬†care provider needs to be assigned to the leave¬†requestor. The person to choose for the alternate must have been the worker's spouse, child,¬†step-child, parent, or guardian for at least five¬†consecutive months prior to taking leave under the FMLA. This form does not replace the employer's medical record in determining eligibility. The employee may be entitled to an employee assistance¬†program(EAP)¬†if needed. The employee cannot be eligible to receive unpaid time-off under section 9(a) of the FMLA with the same type of FMLA leave. To claim FMLA family and medical leave, complete an Employee's FMLA Leave Request Form. 2. Form A/AES/HSS 2.1. Employee¬† Affidavit of Support (PDF) Affidavit Supporting Family Member's FMLA Leave and the Application to Your Employer for FMLA Leave¬† Affidavit Supporting FMLA Leave and EAP or Family Member's FMLA Leave Affidavit Supporting Leave for Medical Reasons ‚ÄĒ An¬†Alternate Care Provider (A/AES/HSS) must be available during the time period a worker is out on¬†FMLA leave. Ineligible Family Member (PDF) Not an eligible relative. The family member of a¬†FMLA leave¬†and the alternate care¬† provider must be listed in the worker's employment record. Any¬† filing of a request for leave in these circumstances will not affect the¬† worker's FMLA leave entitlement. 2.2. Family¬† (PDF) Affidavit of Support for Children of Family Member on FMLA Leave 3. Employee's Serious Health Condition The employee: 1. May be entitled to leave in the first 30 days of the leave period for: a. Treatment for a serious health condition. b. A serious medical condition that would require more than¬†7 days of medical supervision. 2. Must agree with an alternate care provider¬†(A/AES/HSS/HSS/EAP/FAM) for the¬† duration of the leave.

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