Designation Form (Family And Medical Leave Act) printable pdf download

DESIGNATION FORM (Family and Medical Leave Act)

Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform

the employee of the amount of leave that will be counted against the employee’s FMLA leave entitlement. In order to determine whether

leave is covered under the FMLA, the employer may request that the leave be supported by a certification. If the certification is

incomplete or insufficient, the employer must state in writing what additional information is necessary to make the certification complete

and sufficient. Use of this form provides the written information required by 29 C.F.R. § 825.300(c), 825.301, and 825.305(c).

DATE:

_________________________________________________________

TO:

____________________________________________________________________________________________________

(Employee’s name)

FROM: ____________________________________________________________________________________________________

(Agency)

___________________________________________________________________________________________

(Name & title of appropriate agency representative)

PHONE: _________________________________________________________

We have reviewed your request for leave under the FMLA and any supporting documentation that you have provided.

We received your most recent information on ____________________________________ and decided:

Your FMLA leave request is approved. All leave taken for this reason will be designated as FMLA leave.

The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were

initially unknown. Based on the information you have provided to date, we are providing the following information about the

amount of time that will be counted against your leave entitlement:

Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will be

counted against your entitlement:

____________________________________________________________________________________________________

Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or weeks that will be counted

against your FMLA leave entitlement at this time. You have the right to request this information once in a 30-day period (if

leave was taken in the 30-day period).

Please be advised (check if applicable):

You have requested to use paid leave during your FMLA leave. Any paid leave taken for this reason will count against your

FMLA leave entitlement.

We are requiring you to substitute or use paid leave during your FMLA leave.

You will be required to present a medical release certificate to be restored to employment. If such certification is not timely

received, your return to work may be delayed until certification is provided.

A list of the essential functions of your position is attached.

Yes

No (If attached, the medical release certification must

address your ability to perform these functions.)

A FMLA medical release form (NPD – 81) is attached.

Yes

Designation Form

NPD-63

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Rev. 3.13

Designation Form (Family And Medical Leave Act)