Fill and Sign the Fmla Form

FMLA Tracker Form Year Measured from Date of Request – Employees with a Set Schedule Employee's Name ____________________ SSN ____________________ 1. Regular Schedule: __________ day workweek of __________ hours per day. 2. Employee is entitled to 12 weeks of leave per year at __________ hours per week. 3. Employee's total leave allotment for this year is __________ hours. 4. For 12 Month Period Beginning __________ and ending, __________ Date of Leave Request Reason for Leave Hours of Leave Used Hours of Leave Remaining                         How to Use This Form Use this form only if you calculate leave usage based on a twelve-month period measured forward from the date of the leave request. When a leave request is made, note the date of the request on line 4 above as the beginning of the twelve-month period. Use the grid above to track leave used during the twelve-month period identified on line 4. Once that period ends, the employee once again has twelve-weeks of available leave until a new request is made, at which time you should start a new form. • Complete a copy of this form for each of your FMLA eligible employees working a set schedule and maintain it in the employee's file. For employees whose hours vary, do not use this form. Use the variable schedule form. • Based on the employee's regular schedule, determine the number of days per week and hours per day the employee normally works, and note this information on line 1 above. • Multiply the number of days per week and hours per day shown on line 1 and insert the total on line 2. • Multiply the number shown on line 2 by 12 and insert it on line 3. This is the total number of hours of FMLA leave available to the employee this 12 month period. • When a FMLA leave request is approved, note the date of the request and the reason on the form. Once the leave has been completed note the total hours of leave used. • For the initial leave request, subtract the number of hours of leave used from the figure shown above on line 3 to determine the number of hours of leave remaining. Insert that result on the appropriate line for the chart below. Thereafter, with each subsequent leave request in the twelve-month period, subtract the hours of leave used from the remaining leave figure shown for the previous leave request to arrive at a new total for leave remaining. • Begin a new form at the beginning of each designated twelve-month period. Note : This form is meant only as a tool for tracking leave usage and does not replace any normally required leave documentation. Maintain all notices, medical certifications and other documentation of leave in the employee's file.