[Instruction: Insert company letterhead here.]
___ [Instruction: Insert date.]
_____ [Instruction: Insert employee name.]
_____ [Instruction: Insert address.]
_____ [Instruction: Insert city, state, zip code.]
Re: Employee Request for FMLA leave
Dear ____________________: [Instruction: Insert employee name.]
We have received your request dated ____________ [Instruction: Insert date of employee’s
request.] to take time off from work under circumstances that may qualify for leave under the
Family and Medical Leave Act (FMLA). I have enclosed a copy of our FMLA policy along with
forms for both you and your health-care provider to fill out and return. [Comment: If the
request is for other than medical reasons, please delete this language.] This serves as your
notice of FMLA regulations, your rights, and the obligations and expectations of you during
leave. You will be notified in writing about the status of your leave request.
Please fill out and return the enclosed Employee's Request for Family and Medical Leave form
no later than thirty days prior to the first day you are requesting leave. However, if your leave
has been foreseeable for less than thirty days, please fill out and return the form immediately.
The Certification of Health Care Provider (WH-380) form is for your health-care provider to
complete and return. The form may be returned to you or mailed directly to us. I have enclosed a
return envelope for your provider's convenience. Please follow up with us to ensure that we have
received the completed form from your health-care provider within fifteen days of the request. If
there is a delay, your condition or situation will not be certified and this may result in the
discontinuation of your leave. As stated in our enclosed copy of the FMLA policy, your
medical-certification paperwork is considered confidential and will be viewed only by the
person(s) involved in approving your FMLA leave. [Comment: If inapplicable, please delete
this paragraph.]
The Notice and the copy of the company's FMLA policy are for you to keep for your records. It
is recommended that you make a copy of your FMLA request form or ask us to make a copy for
you when you turn it in. All of the information in the Notice is important. However, please pay
extra attention to the section about the continuation of your medical benefits and the use of your
accrued paid time off.
Sincerely,
[Instruction: Insert signature block.]
© Copyright 2012 Docstoc Inc. 1