Family Medical Leave Reporting Form

1Employee Information

2Leave Details

3Intermittent / Episodic Leave

4Reduced Schedule

5Department Details

Please use this form to report the use of Family Medical Leave (FML) for employees in your department. Complete one form for each employee.

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.

Human Resources