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Click ‘Get Form’ to open the FMLA form in the editor.
In Section I, enter the employee's name and employer's name along with the date certification was requested. Ensure you allow at least 15 calendar days for submission.
Proceed to Section II where you will complete your details as the employee. Fill in the family member’s name, select their relationship to you, and describe the care you will provide.
Estimate the amount of leave needed and if applicable, detail any reduced work schedule you may require during this period.
In Section III, provide your health care provider’s information. They will need to complete medical details regarding the family member’s condition and sign off on the form.
Review all sections for accuracy before saving or exporting your completed form for submission.
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The Department has developed optional-use forms which can be used by employers to provide required notices to employees, and by employees to provide certification of their need for leave for an FMLA qualifying reason. These forms are electronically fillable PDFs and can be saved electronically.
What proof do you need to take FMLA?
An employer may require that the need for leave for a serious health condition of the employee or the employees immediate family member be supported by a certification issued by a health care provider. The employer must allow the employee at least 15 calendar days to obtain the medical certification.
What are the rules around FMLA?
ABOUT THE FMLA Eligible employees: Employees are eligible if they work for a covered employer for at least 12 months, have at least 1,250 hours of service with the employer during the 12 months before their FMLA leave starts, and work at a location where the employer has at least 50 employees within 75 miles.
How does FMLA work in Hawaii?
The Family and Medical Leave Act (FMLA) provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.
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This form must be completed by a Health Care Provider when FMLA leave is requested and medical documentation is required pursuant to 512.41, 513.36 and
You have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family and medical reasons, including up to 12 weeks
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