FMLA Case Intake

Konexo FMLA Case Intake

This intake form collects information regarding a federal workers' compensation case. Please provide accurate facts, dates, and documents whenever possible. If you do not know an exact answer, provide your best estimate. This form is for case evaluation and preparation purposes only and does not constitute legal advice.
Purpose of this intake: This form helps Konexo gather key information about your situation so a consultant can review your case before your consultation. Please provide accurate facts and dates to the best of your ability. You may upload supporting documents such as medical records, agency letters, forms, employer notices, and correspondence. Submitting this intake does not create an attorney-client relationship and does not constitute legal advice. A Konexo consultant will review your information and follow up with you about next steps.
CLIENT CONTACT INFORMATION
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
EMPLOYMENT INFORMATION
Employer Name
Work Location or Office
Position Title
Employment Status
Date Employment Began

MonthDayYear
Date
Average Hours Worked Per Week
Supervisor Name
Who is the leave for
Reason for FMLA request
Date leave was first needed

MonthDayYear
Date
Type of leave requested
Estimated duration of leave
Years of Federal Service
FMLA REQUEST INFORMATION
FMLA REQUEST PROCESS
Did you request FMLA leave from your employer?
Date leave was requested

MonthDayYear
Date
Did your employer provide FMLA paperwork?
Did you submit medical certification to your employer?
EMPLOYER RESPONSE
Date certification was submitted

MonthDayYear
Date
Employer response to the leave request
Have you received written notice from your employer regarding the request?
MEDICAL CONDITION INFORMATION
Upload employer letters or notices

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Brief description of the medical condition
Body parts affected
Name of treating medical provider
WORK STATUS AND LIGHT DUTY
Medical provider specialty
Current work status
Were you offered light duty or modified duty?
Did you accept or decline the assignment?
What issue are you currently experiencing with
Did the assignment follow your doctor's work restrictions?
COMPENSATION STATUS
Last day you worked full duty

MonthDayYear
Date
Date the condition began

MonthDayYear
Date
Does the condition require ongoing medical treatment
Has the provider completed an FMLA certification form
Upload medical certification if available

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Did you receive Continuation of Pay (COP)?
CURRENT PROBLEM
Are you currently receiving OWCP wage-loss compensation?
What issue are you currently experiencing with your OWCP case?
Describe the issue in detail
SECTION 9 TIMELINE OF EVENTS

Provide a timeline of important events related to your injury or illness. Examples may include: Date of injury, Medical treatment, Claim filing, OWCP decisions, Light duty assignments, Work status changes.
Provide a description of the problem
SECTION 10 DOCUMENT UPLOAD

Upload any supporting documents related to your case. Examples include: Medical reports, OWCP letters, CA forms, Light duty job offers, Supervisor correspondence, Other evidence.
Provide a timeline of important events related to your FMLA request such as when the condition began, when leave was requested, when certification was submitted, and how the employer responded.
SECTION 11 WHAT HELP ARE YOU SEEKING
Upload supporting documents

Examples: FMLA request forms, Medical certification forms, Employer letters or emails, Attendance records, Disciplinary notices
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What assistance are you seeking from Konexo?
SECTION 12 CERTIFICATION AND SIGNATURE
What is the most urgent issue in your case?
Certification
Printed Name
Digital Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Konexo FMLA Case Intake

CLIENT CONTACT INFORMATION

EMPLOYMENT INFORMATION

FMLA REQUEST INFORMATION

FMLA REQUEST PROCESS

EMPLOYER RESPONSE

MEDICAL CONDITION INFORMATION

WORK STATUS AND LIGHT DUTY

COMPENSATION STATUS

CURRENT PROBLEM

SECTION 9  TIMELINE OF EVENTS

SECTION 10  DOCUMENT UPLOAD

SECTION 11  WHAT HELP ARE YOU SEEKING

SECTION 12  CERTIFICATION AND SIGNATURE

SECTION 9 TIMELINE OF EVENTS

SECTION 10 DOCUMENT UPLOAD

SECTION 11 WHAT HELP ARE YOU SEEKING

SECTION 12 CERTIFICATION AND SIGNATURE