In an effort to serve you in the best possible way due to COVID-19, all FMLA eligibility determination responses will go to the email you provide on this form.
Employees: Submit this FMLA Eligibility Determination Request Form to the Department of Human Resources, Benefits Division, at least 30 days before the leave is to begin, when possible. When 30 days’ advance submission of this form is not possible, submit the request as soon as possible. A late submission of this form may delay your FMLA leave approval.
Supervisors: Please complete if you acquire knowledge that your employee’s absence may qualify for FMLA leave, and the employee is unable to complete the form due to his/her incapacity.
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