Fmla request Form 2020-2023

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 — 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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