MISSOURI DEPARTMENT OF TRANSPORTATION DESIGNATION NOTICE FAMILY AND MEDICAL LEAVE ACT (FMLA) LEAVE Employee’s Name: Home Address: Home Phone Number: Job Title: District/Division/Office: Date: Dear We have reviewed your request for leave under the FMLA and any supporting documentation you have provided. We received your most recent information on . You have requested leave under the FMLA for: the birth of your child the placement (adoption or foster care) of a child with you your serious health condition the care of your spouse/child/parent with a serious health condition the qualifying exigency arising out of the fact that your spouse/child/parent is a member of the Armed Forces on covered active duty or call to covered active duty status the care of an injured/ill servicemember for whom you are the spouse/child/parent/next of kin We have approved your request for FMLA leave. The approved FMLA leave is only for absences related to the reason indicated above. If leave is taken on an intermittent basis you will be required to indicate if an absence is related to your FMLA qualifying event, or if you are requesting leave for another reason, so the department will know how to designate leave. You have anticipated, and we have approved, absences during the following dates: (expected start date) through (expected date of return to work) . You are entitled to 12 26 workweeks of leave under the FMLA. Your approved leave may end sooner than the dates listed above if your qualifying event no longer exists (conditions improve), or if you have exhausted your entitlement during the current 12-month period. The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. If it becomes necessary to request additional time away from work you should do so in writing. (Please see page 2 for additional information about your FMLA leave.) Additional information is needed to determine if your FMLA leave request can be approved. (Please see additional attached page(s) detailing the information needed.) Your FMLA leave request is not approved. The FMLA does not apply to your leave request. You have exhausted your FMLA leave entitlement in the applicable 12-month period.
MISSOURI DEPARTMENT OF TRANSPORTATION DESIGNATION NOTICE FAMILY AND MEDICAL LEAVE ACT (FMLA) LEAVE Employee’s Name: Home Address: Home Phone Number: Job Title: District/Division/Office: Date: Dear We have reviewed your request for leave under the FMLA and any supporting documentation you have provided. We received your most recent information on . You have requested leave under the FMLA for: the birth of your child the placement (adoption or foster care) of a child with you your serious health condition the care of your spouse/child/parent with a serious health condition the qualifying exigency arising out of the fact that your spouse/child/parent is a member of the Armed Forces on covered active duty or call to covered active duty status the care of an injured/ill servicemember for whom you are the spouse/child/parent/next of kin We have approved your request for FMLA leave. The approved FMLA leave is only for absences related to the reason indicated above. If leave is taken on an intermittent basis you will be required to indicate if an absence is related to your FMLA qualifying event, or if you are requesting leave for another reason, so the department will know how to designate leave. You have anticipated, and we have approved, absences during the following dates: (expected start date) through (expected date of return to work) . You are entitled to 12 26 workweeks of leave under the FMLA. Your approved leave may end sooner than the dates listed above if your qualifying event no longer exists (conditions improve), or if you have exhausted your entitlement during the current 12-month period. The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. If it becomes necessary to request additional time away from work you should do so in writing. (Please see page 2 for additional information about your FMLA leave.) Additional information is needed to determine if your FMLA leave request can be approved. (Please see additional attached page(s) detailing the information needed.) Your FMLA leave request is not approved. The FMLA does not apply to your leave request. You have exhausted your FMLA leave entitlement in the applicable 12-month period.
Form%20FMLA2B.docx