Fill and Sign the Instructions for Completing the Medical Leave of Absence Form

EMPLOYEE APPLICATION FOR FMLA (To be filled out by employee) Name: Date of Hire: Reason for Leave (check appropriate reason): Birth of a child or the placement of a child for adoption or foster care. To care for a family member (child, spouse, or parent) with a serious health condition. Your own serious health condition. Answer the following if the leave is for your own serious health condition. What is the nature of your illness? Is hospitalization required? Yes No Are you able to perform the essential functions of the job? Yes No (To be filled out by manager) Does the illness qualify the employee under the provisions of the Americans with Disabilities Act (ADA)? Yes No Explain. If the employee is considered disabled, would a reasonable accommodation under the ADA enable him/her to continue to perform the job? Yes No Is the employee able to perform work of any kind? Yes No Does the employee request all 12 weeks consecutively? Yes No Did you discuss the possibility of intermittent or reduced schedule leave? Yes No Does the employee understand that intermittent or reduced schedule leave will not reduce the total amount of leave available under the FMLA, beyond the amount of leave actually taken? Yes No Would it be better to transfer the employee to another job during intermittent or reduced schedule leave? Yes No Answer the following if the leave is to care for the employee’s seriously ill family member. Does the relationship qualify for FMLA leave? (A son or daughter, biological, adopted, or foster child, a step-child, a legal ward, or a child under 18 years old or 18 or older and incapable of self-care because of a mental or physical disability; a husband or wife, including common-law recognition in certain states; and parents are covered. In-laws are not covered by the FMLA.) Yes No Is in-patient hospitalization of the family member required? Yes No Does the patient require assistance for basic medical, hygiene, or nutritional needs; safety; or transportation? Yes No Explain. Ask the employee to state in his/her own words the care to be provided to the family member and the estimated duration of the treatment. If the employee agrees to an intermittent or reduced schedule leave, put the schedule in writing and have the employee sign it.