FMLA forms are required by several employers for days missed. If you need FMLA forms filled out you must obtain them from your employer - usually from the human resources manager. In addition, this office charges a $25 fee and requires the following form filled out in its entirety:
The information needed on that form is reproduced here:
FMLA Information sheet
There is a $25 fee for filling out all forms and letters, including FMLA forms. Please make sure all information on this sheet is correct to ensure the forms do not need to be amended, as you will need to pay the fee each time a form is filled out. We cannot fill out forms if you have not been seen here for the illness or condition.
Name: __________________________________ Date of Birth: ___________________
Is this FMLA for you? __________ Nature of the illness: _________________________
Is FMLA to care for someone else? ____________ Relationship to you: _____________
Reason you need time off to care for this person: ________________________________
Have you seen other providers for this illness? What dates? ________________________
Date you would like FMLA to start: _____________________
Date you would like FMLA to stop: _____________________
Would you like FMLA on an intermittent basis? If so, how often do you think you will need leave: (for example, 3 times a month) _____________________
How long will those episodic absences last: (for example, one day each) _____________
Would you like FMLA on a reduced schedule basis? If so, how many hours a day do you think you can work: (for example, 6 hours a day) _____________________