Family Medical Leave Act (FMLA)

Information

Employee Rights under FMLA

Department of Labor COVID-19 FMLA Changes

Request Forms

FMLA Request Form

FFCRA Leave Request FormDownload

The FFCRA form should be used for one of the following reasons, all other requests should use the FMLA Request Form:

  • You are subject to a federal, state, or local quarantine or isolation order related to COVID-19
  • You have been advised by a health care provider to self-quarantine due to concerns related to COVID-19
  • You are experiencing symptoms of COVID-19 and are seeking a medical diagnosis.
  • You are caring for an individual who is subject to either numbers 1 or 2 above.
  • You are caring for a child (up to age 14, or age 15-18 with special circumstances) whose school or place of care has been closed, or your childcare provider is unavailable due to COVID-19 precautions and,
    • You attest that no other suitable person is available to care for your child during the requested period of leave; and/or
    • You attest that special circumstances exist requiring your need for leave to care for a child ages 15-18.
  • You are experiencing another substantially similar condition specified by the Secretary of Health and Human Services in consultation with the Secretary of the Treasury and Secretary of Labor.

Certification FOrms