Name Empl ID Date of Hire (state) Leave Balances Sick Other – Annual Other – Request Requested Dates # Hours Requested Eligibility Findings Employed with state of gov’t for 12 YES NO months as of FMLA start date Scheduled Hours - Work status for at Hours - least 1,250 hours during 12 months YES NO Leave/Comp Taken - preceding FMLA Suspen/Furlough Hrs = start date Hours Worked Birth of child (within 12 months of birth) Adoption or foster care of child (within 12 months of placement) Care of family member with serious health condition Spouse Child Parent Employee’s serious health condition Reason for leave Qualifying exigency – Spouse Child Parent deployed to foreign country Care of family member with serious injury/illness from active military duty Spouse Child Parent Other (Employee is nearest blood relative) # Hours of FMLA used in 12-mo pd # Hours remaining FMLA eligibility Determination Eligible for YES NO Requested FMLA Dates in Pay Status Dates on LWOP Comments
Name Empl ID Date of Hire (state) Leave Balances Sick Other – Annual Other – Request Requested Dates # Hours Requested Eligibility Findings Employed with state of gov’t for 12 months as of FMLA start date YES NO Work status for at least 1,250 hours during 12 months preceding FMLA start date YES NO Scheduled Hours - Hours - Leave/Comp Taken - Suspen/Furlough Hrs = Hours Worked Reason for leave Birth of child (within 12 months of birth) Adoption or foster care of child (within 12 months of placement) Care of family member with serious health condition Spouse Child Parent Employee’s serious health condition Qualifying exigency – Spouse Child Parent deployed to foreign country Care of family member with serious injury/illness from active military duty Spouse Child Parent Other (Employee is nearest blood relative) # Hours of FMLA used in 12-mo pd # Hours remaining FMLA eligibility Determination Eligible for Requested FMLA YES NO Dates in Pay Status Dates on LWOP Comments
FMLA%20Eligibility%20Worksheet.docx