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
Please Contact Us if you need a copy of this letter.
- FMLA Pattern Evaluation Form
Please Contact Us if you need a copy of this form.
- 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 - Health 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. If a Release
to Return was requested at FMLA designation; 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 an employee may be infectious, when the employer has knowledge of
limitations/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 an employee may be infectious, when the
employer has knowledge of limitations/restrictions and/or has safety concerns.
If a release is required for an employee returning from FMLA, the employee must
be notified of the requirement via the Designation Notice. 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
Page last updated December 2012