Fill and Sign the Fmla Paper Form

FMLA Tracker Form Calendar/Fiscal Year Method – Employees with a Variable Schedule Employee's Name ______________________ SSN ______________________ For Twelve-Month Period Beginning ___________ and ending, ___________ 1. Average Number of Hours Worked Per Week: ___________ (based on a review of the twelve-week period ___________ to ___________ ) 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. 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 use the calendar year, your fiscal year, or another designated twelve-month period to calculate the twelve-month period for FMLA leave usage. • Complete a copy of this form for each of your FMLA eligible employees working a variable schedule and maintain it in the employee's file. For employees working a set schedule, do not use this form. Use the set schedule form. • Determine the average number of hours worked per week by the employee by reviewing and averaging the employee's hours in the twelve-weeks preceding the request. Note this information on lines 1 and 2 above. • 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 twelve-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.