This form is an application for Family and Medical Leave. It is to be filled out by an employee who is requesting a leave of absence.
Fmla Application Forms For Pregnancy
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
Instant download
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FAQ
FMLA guarantees the employee's job and insurance benefits during this time. This includes care related to pregnancy either for prenatal care visits, illness prior to delivery, or for recovery and bonding time after you have your baby.
If eligible, you can receive benefit payments for up to eight weeks. Payments are about 60 to 70 percent of your weekly wages earned 5 to 18 months before your claim start date. You will receive payments by debit card or check it's your choice!
An employee's ability to use FMLA leave during pregnancy or after the birth of a child has not changed. Under the regulations, a mother can use 12 weeks of FMLA leave for the birth of a child, for prenatal care and incapacity related to pregnancy, and for her own serious health condition following the birth of a child.
Dear (Supervisor / HR Manager): Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave.
Yes. The birth of a child, or complications relating to childbirth or pregnancy, would qualify under FMLA as a serious health condition.
More info
The FMLA form you submit to your employer will have a start date for the period of time you are "incapacitated," typically the day of delivery. You and your health care provider must fill out this form about your serious health condition.INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your medical provider. Accrued leave during your maternity leave. FMLA is a type of leave without pay. O If so, be sure to complete necessary forms in PeopleSoft self-service. If you would like to apply for these benefits during your pregnancy and recovery, complete the Temporary Disability Benefits Application (form DS-1). Submit the completed form, using the Human Resources contact information listed on the form. Do not attach medical documents to your leave request in Workday.