Family Medical Leave Reporting Form

Please use this form to report the use of Family Medical Leave (FML) for employees in your department. Complete one form for each employee. Please note that this form should only be used to report the 12 weeks of FML. The full duration of parental leave does not need to be reported.

Employee Information

Type of Reporting

New entry

Correction of previous entry

Last name

First name

Employee ID

Pay Schedule

Salaried

Hourly

Based on their regular schedule, report the hours and days the employee works. If hourly, use an average.

Hours worked per week

Please enter a number less than or equal to 40.

Days worked per week

Please enter a number less than or equal to 7.

Colorado State University

Human Resources

Family Medical Leave Reporting

Employee Information

Leave Details

Intermittent/episodic

Reduced schedule