University Of Michigan - Family And Medical Leave Act Of 1993 (Fmla) Tracking Form - 2015
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1FAMILY AND MEDICAL LEAVE ACT
Form
Form
HR36608
HR36608
OF 1993 (FMLA) Tracking Form
This form is to be used to track employee FMLA qualifying absences.
First Name:
Last Name:
Middle Name:
UMID:
Department:
FMLA Benefi t Year:
Calendar
Days* or
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
Month
Hours**
Used
Jan
0.00
0.00
Feb
0.00
Mar
Apr
0.00
0.00
May
0.00
Jun
0.00
Jul
Aug
0.00
Sep
0.00
0.00
Oct
Nov
0.00
Dec
0.00
0.00
TOTAL:
*If using calendar days, there is a maximum of 84 calendar days (12 weeks x 7 days) of FMLA coverage. Tracking an FMLA
absence with calendar days is only appropriate for con nuous absences.
**If using hours, the maximum dura on of FMLA coverage is determined by mul plying twelve weeks by the employee’s
regularly-scheduled hours per week (for example, 12 weeks x 40 hours = 480 hours). Time is recorded by hours taken on a
regularly scheduled work day. Hours can be used to track a con nuous absence and is the preferred method for tracking the
intermi ent use of FMLA eligibility and reduced schedules.
If the employee transfers to another department prior to the end of the FMLA benefi t year, a copy of this form should be
forwarded to the new department.
Form HR36608
Revised 2/2015
Available at: h p://
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