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FMLA & VESSA Letter Template

FMLA Form And Instructions

The Family and Medical Leave Act (FMLA) form is used to grant eligible employees up to 12 weeks of leave entitlement for the birth or adoption of a child; for the care of a child, spouse, or parent who has a serious health condition; when an employee is unable to perform the function of his or her position due to a serious health condition; or for a qualifying military-related exigency; or up to 26 weeks of leave entitlement for the care of an ill/injured covered servicemember.

Carefully read the Employee Rights and Responsibilities section before completing the FMLA form. The employee requesting leave should complete the FMLA application section of the form (except in cases where the employee is incapacitated). The employee’s Health Care Provider should complete the FMLA Medical Certification section of the form.

FMLA Form in PDF which requires Adobe Acrobat Reader
FMLA Form in Rich Text Format (RTF) for download

FMLA Certification Forms:
For Employee’s Serious Health Condition: PDF | RTF
For Family Member’s Serious Health Condition: PDF | RTF
For Serious Injury or Illness of Covered Servicemember: PDF | RTF
For Qualifying Exigency for Military Family Leave: PDF | RTF

VESSA Form And Instructions

The Victims’ Economic Security and Safety Act (VESSA) form is used to grant up to 12 weeks of leave entitlement to eligible employees who are victims of domestic or sexual violence or who have a family or household member who is a victim.

Carefully read the Employee Rights and Responsibilities section before completing the VESSA form. The employee requesting leave should complete the VESSA application (except in cases where the employee is incapacitated). If medical certification is required, the employee’s Health Care Provider should complete the FMLA Medical Certification form.

VESSA Form in PDF which requires Adobe Acrobat Reader
VESSA Form in Rich Text Format (RTF) for download