Sample Notice of FMLA Leave Approval

You have requested leave which is covered under the federal Family and Medical Leave Act (FMLA). This notice confirms the terms of your leave.

Employee______________________________________________

Duration of Leave - Beginning_________________ Ending____________________
___ Regular Leave
___ Intermittent Leave
___ Reduced Leave Schedule

Reason for Leave
___ Employee's Own Serious Health Condition
___ Care for Family Member with Serious Health Condition (explain)
___ Care for Newborn or Newly-placed Child

Required Medical Certification(s)
___ Certification of Health Care Provider as to medical necessity for leave - must be provided to employer PRIOR to beginning leave
___ Fitness-for-Duty Certification - must be submitted to employer PRIOR to returning to work

Compensation During Leave
___ Paid Leave
___ Unpaid Leave
___ Combination (describe)

Health Insurance
___ Continue coverage - employee will pay $______ to employer as follows: __________
___ Continue coverage - employer pays all premiums
___ Employee has elected to discontinue coverage during leave

Other Benefits (Specify)
___ Continue coverage - employee will pay $______ to employer as follows:___________
___ Continue coverage - employer pays all premiums
___ Employee has elected to discontinue coverage during leave
___ Other

Required Reports During Leave (employee will call to report status)
___ Weekly
___ Monthly
___ Other

Additional Information

Employer Signature:_____________________________________ Date:______________

Employee Signature:_____________________________________ Date:______________