Quincy Area Command FMLA Request Form

Quincy Area Command FMLA Request Form

Under the Family and Medical Leave Act, if you have worked at least one year and at least 1,250 hours in the past 12 months, you are eligible for up to 12 weeks unpaid leave under specific circumstances. You are entitled to receive health benefits as if you were still working. When returning to work, you must be reinstated to the same or an equivalent job with the same pay, benefits and terms and conditions of employment. If you do not return to work following the FMLA leave (for a reason other than the continuation, recurrence or onset of a serious health condition which would entitle you to FMLA leave or other circumstances beyond your control), you may be required to reimburse us for our share of health insurance premiums paid on your behalf, if any, during your FMLA leave.

Today's Date:

Name

First NameLast Name

Title:

Department:

Preferred Contact Information for Follow-Up:

(Phone number or email address)

I am requesting FMLA for the following reason:

Other

Are you requesting intermittent leave? (Leave taken in separate blocks of time due to a single qualifying reason.)

If "yes" to intermittent leave, please provide an explanation of the proposed schedule and frequency of leave.

Date leave is anticipated to begin:

Date leave is anticipated to end:

Certification and Acknowledgement:

I understand that I may be required to provide medical certification or other supporting documentation for my FMLA leave request. I also understand that failure to provide the required documentation may result in a delay or denial of my request.

Certification and Acknowledgement: By selecting one of the options below, I certify that the information provided is accurate and truthful.

Authorization:

I authorize a human resource professional to contact my healthcare provider to clarify and/or confirm the medical certification I provide. I understand that if I deny permission to contact my healthcare provider and I do not otherwise clarify an unclear medical certification, my employer may deny the designation of my leave as FMLA.

Authorization: By selecting one of the options below, I authorize The Salvation Army to contact my healthcare provider for additional information.

Please sign to certify the accuracy of information provided and authorization to contact your healthcare provider.