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 (Family and Medical Leave Act) is a federal law that provides eligible employees with the right to take unpaid, job-protected leave for specific family and medical reasons. To request FMLA leave, employees must fill out an FMLA form, also known as the Certification of Health Care Provider form. This form is crucial in documenting the employee's need for leave and ensuring compliance with FMLA regulations. When filling out the FMLA form, employees are required to provide detailed information about their own medical condition or the medical condition of their family member for whom they need to care. The form typically consists of several sections, including personal information, medical information, and details about the requested leave duration. In the personal information section of the FMLA form, employees must provide their name, social security number, contact information, and their relationship with the family member in need of care. This section helps the employer validate the employee's eligibility for FMLA leave. The medical information section of the form requires employees to disclose the medical condition being addressed. They must provide a detailed description of the condition, its symptoms, and any necessary treatment or care. Additionally, if the FMLA leave is taken to care for a family member, the employee needs to include the family member's name, relationship, and their ability to provide care. Once the medical condition is described, the employee's health care provider must fill out the remaining sections of the form. This includes information about the medical provider's name, contact information, and their professional qualifications. They must also provide a thorough assessment of the medical condition, stating whether it meets the criteria for FMLA leave. Notably, there are various types of FMLA form filled out examples, depending on the specific circumstances. Some examples include: 1. Medical Certification Form (FMLA form WH-380-E): Used when an employee's own serious health condition requires leave. 2. Certification of Health Care Provider for Family Member's Serious Health Condition (FMLA form WH-380-F): Used when an employee needs to care for a family member with a serious health condition. 3. Certification of Qualifying Exigency for Military Family Leave (FMLA form WH-384): Used when an employee needs to take leave due to a qualified exigency arising from the covered active duty or call to covered active duty of their spouse, parent, child, or next of kin. 4. Certification for Serious Injury or Illness of Covered Service member — for Military Family Leave (FMLA form WH-385): Used when an employee needs to care for a covered service member with a serious injury or illness. These examples illustrate the variety of FMLA forms that employees may need to fill out depending on their specific circumstances. It is crucial to ensure accurate and complete filling out of these forms to validate the need for FMLA leave and protect employees' rights under the law.
