HR Management & Compliance

FMLA —Never Easy, But These Pre-Written Forms Will Help

In yesterday’s Advisor, we covered FMLA fitness-for-duty certifications and offered a handy form for requesting the certifications. Today, two more FMLA forms plus an introduction to the “FMLA Bible.”

FMLA is never going to be easy, but with forms ready to go for most FMLA situations, you can make it a little easier. Here are two more FMLA forms you will find helpful.

[Go here for “Fitness for Duty Certification Form.]

FMLA Employee Statement of Family Relationship

Under the FMLA, to confirm a family relationship, the employer may require the employee giving notice of the need for leave to provide reasonable documentation or statement of family relationship. This documentation may take the form of a simple statement from the employee, or a child’s birth certificate, a court document, etc. The employer is entitled to examine documentation such as a birth certificate, etc., but the employee is entitled to the return of the official document submitted for this purpose.


In support of my request for medical leave dated _________________
to care for (name) _________________________________
who is my (check one):
____ Spouse
____ Child
____ Mother
____ Father
____ Next of kin
due to his or her serious medical condition, I have attached a copy of the following:
____ Birth certificate
____ Marriage certificate
____ Court document: _________________________________________
I hereby certify that (name) _______________________________________
is my (check one):
____ Spouse
____ Child
____ Mother
____ Father
____ Next of kin
I understand that any deliberate misrepresentations made in this statement are punishable pursuant to the company’s policies regarding misrepresentations by employees. I certify that all of the statements made herein are true and accurate to the best of my knowledge and belief.

Employee Name: _______________________________________
Employee Signature: ____________________________________
Date: ________________________________________________

FMLA changes—the #1 hassle of 2010, and likely of 2011. BLR’s compliance guide is ready to help now. Click here to find out more about the Family and Medical Leave Act Compliance Guide.

FMLA Leave Periodic Status Report

Another form that most employers will require is the periodic status report. This report, when required consistently, can be a great help in controlling leaves.


Employee: Please be advised that pursuant to the federal Family and Medical Leave Act, we are entitled to make periodic inquiries regarding any changes in your status and intentions to return to work at the conclusion of your leave. Accordingly, please complete this form and return it to Human Resources, to the attention of ____________________, on or before ___________________.

Employee Name: ________________________
Title: __________________________________
Department: ____________________________
Leave Request Dated: ____________________
Approved By: ___________________________
Reason for Leave: ___________________________________________

[   ] I hereby reaffirm my intention to return to work on _______________; or

[   ] You are hereby advised that I no longer intend to return to work on my scheduled return-to-work date for the following reason:
I request a new return-to-work date of _______________________; or

[   ] I do not intend to return to work.

Employee Signature: ______________________________
Date: __________________________________________

It’s an almost overwhelming task to keep up with the FMLA, and recent, far-reaching changes haven’t helped. And that’s to say nothing of the devilish complexity of marrying FMLA with ADA and workers’ comp. Good news! BLR’s editors have gone the extra mile to get your comprehensive compliance guide up to date.

BLR’s recently updated Family and Medical Leave Act Compliance Guide—the book some are calling the “FMLA Bible”—simplifies the frustrating and confusing complexities of the FMLA, so you know exactly how to comply in every situation.

It contains practical answers to all the FMLA questions you are asking—and the ones you haven’t thought of but should be asking.

A whirlwind of changes has hit the FMLA—are you ready to comply? Order BLR’s comprehensive guidebook and find out what you need to do. You’ll get expert FMLA guidance, forms, and concrete examples. Find out more.

The Family and Medical Leave Act Compliance Guide includes:

  • Leave law overview
  • All the new forms and advice on how to use them
  • Practical guidance on implementing all aspects of the new rules
  • Analysis of federal and state laws, what they require, and how they interact
  • Leave circumstances, coverage, and eligibility—for FMLA, ADA, workers’ comp, and military leave
  • Recordkeeping and reporting requirements
  • Reasonable accommodation
  • Sample policies and forms
  • Plus a quarterly newsletter and updates to make sure you stay in compliance as any changes come about

Get more information or order your copy of the Family and Medical Leave Act Compliance Guide.

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Leave Policy, Compliance