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Archdiocese of Washington - FMLA INTAKE FORM FMLA is requested for Employee s own illness To care for a family member Employee Name Employee Email Address Employee Telephone Number Employee Address Date of Hire Weekly Hours Employee Job Title Employee s Last day of Work Available Paid Leave Time Sick NRI Vacation Applicable to Employee illness only Condition If pregnancy include due date Employing Location Name and Address Employer Contact Additional information Please send completed forms to...

How to fill out fmla intake form

How to fill out an FMLA intake form:

1. Start by carefully reading through the form to understand the information required and the purpose of each section.
2. Begin by providing your personal information, such as your name, address, phone number, and email address. Make sure to double-check the accuracy of the information you provide.
3. Fill in your employee identification details, including your job title, department, and supervisor's name.
4. Indicate the type of leave you are applying for, whether it's for your own serious health condition, the care of a family member, or military exigency. Specify the start and end dates of the requested leave.
5. If applicable, indicate if your leave is to bond with a newborn child, a newly adopted child, or a foster care placement.
6. Provide details about the medical condition you or your family member is experiencing, if applicable. This may include the name of the healthcare provider, diagnosis, treatment details, and expected duration of the condition.
7. If you need intermittent leave, specify the estimated frequency and duration of the leave required.
8. Indicate the type of certification you are attaching to support your FMLA leave request. This could be a medical certification form completed by your healthcare provider or other relevant documentation.
9. Sign the form and indicate the date of submission. Keep a copy for your personal records.

Who needs an FMLA intake form:

1. Employees who require leave under the Family and Medical Leave Act (FMLA) from their job due to their own serious health condition, the care of a family member, or military exigency, need to fill out an FMLA intake form.
2. The FMLA provides certain job-protected, unpaid leave for eligible employees, allowing them to balance work and family responsibilities without the fear of losing their job.
3. Individuals who have recently adopted a child, had a newborn child, or taken in a foster care placement may also need to fill out an FMLA intake form to request leave for bonding purposes.
4. The FMLA intake form helps gather the necessary information to determine if an employee is eligible for and entitled to FMLA leave. It enables the employer to assess the employee's situation and make informed decisions regarding their leave request.

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What is fmla intake form?

FMLA intake form is a form used to request leave under the Family and Medical Leave Act (FMLA).

Who is required to file fmla intake form?

Employees who are eligible for FMLA and need to take leave for qualifying reasons are required to file FMLA intake form.

How to fill out fmla intake form?

FMLA intake form can be filled out by providing necessary information such as employee details, reason for leave, expected duration, and medical certification if required.

What is the purpose of fmla intake form?

The purpose of FMLA intake form is to formally request and document the need for leave under FMLA and ensure compliance with the law.

What information must be reported on fmla intake form?

Information such as employee details, reason for leave, expected duration, and any medical certification if required must be reported on FMLA intake form.

When is the deadline to file fmla intake form in 2023?

The deadline to file FMLA intake form in 2023 will depend on the specific circumstances and the start date of the requested leave.

What is the penalty for the late filing of fmla intake form?

The penalty for late filing of FMLA intake form may result in delayed approval of leave or potential denial of FMLA protection for the requested leave period.

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