Fmla Notification Form - Sikich Llp (Page 2 of 3) in pdf

Fmla Notification Form - Sikich Llp Page 2

[Company Letterhead]

Employee Name

Address

Dear:

We have received information indicating that you may be eligible for a leave under the Family and

Medical Leave Act (FMLA). Enclosed is the [Company Name] and Medical Leave Policy outlining

your rights and obligations, along with a Notice of Eligibility and Rights & Responsibilities (FMLA)

Department of Labor Form (WH-381) and a Certification of Health Care Provider for Employee’s

Serious Health Condition Form (WH-380-E).

Since you are seeking a leave as defined in the attached Family and Medical Leave (FMLA) Policy

[Revised 1/09], we are granting you FMLA on a provisional basis pending your timely submission of

the completed Certification of Health Care Provider Form. After we receive the Certification of health

Care Provider Form you will receive a Designation Notice (Family and Medical Leave Act) Department

of Labor Form (WH-382) within five (5) business days of the receipt of the Certification of Health Care

Provider Form which will provide you with information on your eligibility for leave and the amount of

time that will count towards the annual 12-week allotment of FMLA time off. We require that you use

accrued and unused Paid Time Off in the following manner: Sick, Vacation, and then Personal Time

(allowing you to retain two (2) weeks’ vacation time) for FMLA time that is for your own serious

illness.

Your failure to return the completed Certification of Health Care Provider Form and/or

appropriate documentation in a timely manner will delay the start of your FMLA medical leave

and your time off during the period of delay will be handled in accordance with the [company

name] attendance policy.

If you have any questions, please contact ____________ at ______________________

Sincerely,

Encl/cm:

Notice of Eligibility and Rights & Responsibilities

Family and Medical Leave, Notice of Eligibility and Rights & Responsibilities

Acknowledgement Form

Certification of Health Care Provider for Employee’s Serious Health Condition

Employee Job Description

FMLA Policy

Cc:

Fmla Notification Form - Sikich Llp Page 2