FMLA Hours Worked

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					                              FMLA Hours Worked

[Fill out this worksheet for each employee who requests leave, to verify that the employee
is eligible under the FMLA. Don’t put more than one name on the worksheet—the
information should go in each employee’s confidential file. If an employee requests
multiple leaves in the same year, simply add rows to the worksheet.]

  Employee Name             Start Date          Hours Worked in      Dates FMLA Leave
                                              the 12 Months Prior          Taken
                                              to Requested Leave

Work  Session Work Session Owner
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