Employee FMLA Eligibility Determination Request 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.

Note: * indicates field is required

  • I am requesting family/medical leave for the following reasons: (check all that apply)
  • Additional information about employee FMLA rights and responsibilities will be provided to you in writing within five business days from receipt of this notice (unless already provided).


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