Fmla Intermittent Leave Tracking Form printable pdf download

Fmla Intermittent Leave Tracking Form

FMLA Intermittent Leave Tracking Form

This FMLA leave tracking form must be submitted to the HR Benefits Department by the 10

of each month while an employee is on an approved

Family and Medical Leave. This will assist the HR Benefits Department with tracking the number of days/hours that an employee has used for an

approved FMLA intermittent leave.

Employee Name: __________________________________

AISD ID Number: ____________ Campus/Location ______________________

Leave Start Date: _____________________ Estimated Leave End Date: ________________________

Please indicate amount of FMLA leave taken each day (in one hour increments). ONLY FMLA TIME SHOULD BE RECORDED ON THIS

FORM.

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Hours

Used

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

Total FMLA days/hours Used: __________ Remaining days/hours: __________

I hereby certify that all hours recorded on this form were related to an approved FMLA Intermittent Leave. I understand that it is my

responsibility to furnish the HR Benefits Department with certification for absences related to my serious health condition or my family

member’s serious health condition every thirty days.

_______________________________________ __________________

______________________________________ __________________

Employee Signature

Date

Principal/Supervisor Signature

Date

Fmla Intermittent Leave Tracking Form