Forms and Letter Templates
To ensure that you are using the current form, please download a new copy with each use.

See the corresponding section of this website for information related to leave and/or disability processes.  Contact FSDS if information beyond the form content and/or letters is being requested.

Leave

• Non-FMLA Continuous Medical Leave Request Letter (letter, docx)
  The Non-FMLA Leave Request letter is sent to an employee when the employer has knowledge of need for continuous absence not eligible for FMLA is not available. This letter is sent in conjunction with the Non-FMLA Leave Request Form.
  
  
• Non-FMLA Leave Request Form and Release of Information Form (form, pdf)
  The Non-FMLA Leave Request Form and Release of Information is sent in conjunction with the request letter, and is completed by the treating health provider to indicate medical necessity of a continuous leave. A release of information is enclosed to provide consent for FSDS staff to communicate with the THP if the returned documentation is insufficient to determine workplace needs.
  
  
• Confirmation of FMLA Intermittent Absence Exceeding Approval (letter, docx)
  This letter is sent to an employee when treating health provider confirmation is required to consider authorization of absences exceeding original intermittent FMLA approval. The first occasion of overuse should include a conversation with the employee and absence should be approved if reasonably explained. This letter is used on the second occasion of overuse. Without additional information, further absences in excess of original designation will not be authorized as FMLA.
  
  
• FMLA Pattern Evaluation Letter (letter, docx)
  This letter is used when employer evaluation of absence indicates potential pattern of absence, e.g., days, hours that is observed for an unpredictable health condition and the pattern has been observed for at least three absences and one month duration. This letter is sent after conversation with the employee to the employee in conjunction with the FMLA Pattern Usage Form. If the form is not returned, contact FSDS to determine status of future absence.

• FMLA Pattern Evaluation Form (form, pdf)
  The FMLA Pattern Evaluation Form is sent in conjunction with the FMLA Pattern Evaluation letter, and is completed by the treating health provider for the FMLA approved health condition. The completed form must be returned for any continued pattern of absences to be considered for approval.
  
  
• Adult Child FMLA Eligibility Letter (letter, docx)
  The Adult Child FMLA Eligibility Letter is sent to an eligible employee who seeks absence from work to care for a child 18 years and older.  This letter is sent in conjunction with the FMLA Eligibility Form
  
  
• Adult Child FMLA Eligibility Form (form, pdf)
  The Adult Child Eligibility Form is sent in conjunction with the Adult Child FMLA Eligibility Letter, and is completed by the child's treating health provider.  The department is to contact FSDS to determine if the adult child’s needs meet FMLA criteria.
  
  
• FMLA Eligibility Notice (form, pdf)
  The FMLA Eligibility Notice is sent to an employee notifying of eligibility status for FMLA.  This form is sent within 5 business days of knowledge of potentially qualifying FMLA absence.
  
  
• FMLA Designation Notice (form, pdf)
  The FMLA Designation Notice is sent to an employee in notification of approval, denial, or insufficient information to determine FMLA eligibility.  This form is sent within 5 business days of receipt of information regarding absences considered for FMLA.

Leave - Heath Certification Forms

• FMLA Self Health Certification Form (form, pdf)
  The FMLA Self Health Certification Form is sent  to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee may need to be absent from work due to his/her own health, and the employer does not have sufficient information to determine absence eligibility.  The treating health provider of the health condition completes this form.
  
  
• FMLA Family Health Certification Form (form, pdf)
  The FMLA Family Health Certification Form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to an eligible family member's health and the employer does not have sufficient information to determine absence eligibility.  The treating health provider of the family member's health condition completes this form.
  
  
• FMLA Certification for Serious Injury or Illness of Covered Servicemember - for Military Family Leave (form, pdf)
  The form sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to an eligible military family member injury, and the employer does not have sufficient information to determine absence eligibility for FMLA.  The Department of Defense or the treating health provider of the health condition completes this form.
  
  
• FMLA Certification of Qualifying Exigency for Military Family Leave Form (form, pdf)
  The FMLA Certification of Qualifying Exigency for Military Family Leave Form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to military family member's deployment and the employer does not have sufficient information to determine absence eligibility.  The form is completed by the employee.

Leave - Exhaustion Letters

• FMLA Exhaustion and Following Status (letter, docx)
  The FMLA Exhaustion letter should be sent to an employee when calendar year FMLA is anticipated to exhaust within 4-6 weeks and information is necessary to determine needs beyond FMLA.  Enclose a Release to Return to Work Form if the employee is currently absent, as well as a non-FMLA Leave Request Form if the employee has or will exhaust paid leave before anticipated return date.  Enclose a Medical Information Request Form if the employee is currently working and the employer has knowledge of limitations impacting his/her ability to attend work.  Include FSDS in communication regarding knowledge of need for non-FMLA unpaid leave.
  
  
• Non-FMLA Unpaid Medical Leave Exhaustion and Following Status (letter, docx)
  The letter should be sent to an employee 4-6 weeks prior to exhaustion of approved, non-FMLA unpaid medical leave and knowledge of return or continued need for leave is necessary.  Enclose a Release to Work Form, EMJFA, and non-FMLA leave Request Form.

Disability

• Medical Information Request Form (MIRF) Letter (letter, docx)
  The Medical Information Request letter should be sent to an employee when a health limitation is disclosed and the department does not have sufficient information to determine the limitation(s) impact on work. 
  
  
• Medical Information Request Form (MIRF) and Release of Information (form, pdf)
  The form (MIRF) should be sent to an employee in conjunction with the MIRF letter and is completed by the employee's treating health provider for the health condition’s limitations in question.  A release of information is enclosed to provide consent for FSDS staff to communicate with the THP if the returned documentation is insufficient to determine workplace needs.  The completed MIRF is to be forwarded to FSDS for implementation of the interactive process, as applicable.
  
  
• Interactive Disability Accommodation Document (IDAD) (form, pdf)
  The IDAD is completed at the completion of the interactive process by the department to record a reasonable accommodation offered by the employer.  The employee indicates agreement or disagreement and may complete the Appeal Form if the accommodation offered does not accommodate health limitations.  After signatures are obtained, a copy of the IDAD is forwarded to FSDS.
  
  
• Disability Accommodation Appeal Form: Employment (form, pdf)
  The Disability Accommodation Appeal Form is completed by an employee when a reasonable accommodation is offered by the department, and an employee does not agree with the accommodation offered.
  
  
• Release of Information Form (form, pdf)
  The Release of Information Form is used to give authorization for FSDS staff to contact treating health providers.  This form is completed by the employee and the signature signing must be witnessed.  The authorization is used by FSDS when medical information is insufficient to determine an employee's health limitation (s) and/or impact to the work environment or in FMLA situations when medical documentation was not cured in the additional seven days.

Return to Work

• Release to Work Letter (letter, docx)
  The letter should be sent to an employee when the employer has determined that more sufficient medical information is necessary for the employee to return to work following an absence.  The letter should be used following hospitalization, for absences of more than two weeks, when the employer has knowledge of restrictions and/or has safety concerns.  The Release to Work Form is sent in conjunction with this letter.
  
  
• Release to Work Form (form, pdf)
  The Release to Work Form should be sent in conjunction with the Release to Work Letter, or included as a separate document in exhaustion letters.  This Form should be used following hospitalization, for absences of more than two weeks, when the employer has knowledge of restrictions and/or has safety concerns. If a release is required for an employee returning from FMLA, the employee must be notified when the leave is initially designated.  The Release to Work Form is to be included in the notification. 
  
  
• Temporary Restricted Work Plan Letter (letter, docx)
  The Temporary Restricted Work Plan letter may be used to record an employer's ability to provide work within minor/transitory restrictions of less than one to two months, restricted work hours if paid leave exists, and the restrictions are related to a non-occupational health condition.  If restrictions exceed minor/transitory definition, see FSDS website to begin the interactive process.

General

• Essential/Marginal Job Function Analysis (EMJFA) (form, pdf)
  The Essential/Marginal Job Function Analysis is completed by the employer to provide information of a position's essential and marginal job duties, as well as required abilities to perform job functions and is used to supplement job descriptions when further description is necessary.
  
  

Page last updated April 2012