The Family and Medical Leave Act (FMLA) is a federal law that provides eligible employees of covered employers with unpaid, job-protected leave for certain family and medical reasons. In addition to providing eligible employees with leave for qualifying reasons, covered employers must maintain employees’ health benefits during leave and restore employees to their same (or equivalent) jobs after leave. In general, the FMLA covers private-sector employers with 50 or more employees and governmental employers of any size. 

This checklist outlines key steps for employers to process an employee’s request for FMLA leave. Keep in mind that complying with the FMLA may involve additional steps depending on the facts of a specific situation. Also, many states (and some localities) have their own family and medical leave laws that provide broader leave protections to employees. Employers will need to comply with the FMLA and any applicable state and local leave laws.

FMLA Leave Request

Employee name

Date of leave request*

Dates of anticipated leave

* An employer may learn of a request for FMLA leave when the employee submits a request or when the employer acquires knowledge that an employee needs leave that may be for an FMLA-qualifying reason. When requesting FMLA for the first time, an employee is not required to specifically mention the FMLA. However, the employee must provide enough information for the employer to know that the leave may be covered by the FMLA.

Determining Employee Eligibility

                    Employee Eligibility                                                                     Yes                No

Is the employee eligible for FMLA leave?
To be eligible for FMLA leave, an employee must satisfy 
ALL the following criteria:

• The employee works for an employer covered by the FMLA;
• The employee has worked for the employer for at least 12                     ☐               ☐
months as of the date leave is to start (it does not need to be 
consecutive);                                                                                            
• The employee has at least 1,250 hours of service for the 
employer during the 12-month period before the leave is to start; 
and
• The employee works at a location where the employer has at 
least 50 employees within 75 miles of that worksite. 

Is the employee’s leave for a qualifying reason?
Is the leave for one of the following FMLA-qualifying reasons?
• The birth of a child and to bond with the newborn child within 

one year of birth;
• The placement of a child for adoption or foster care and to bond 
with the newly placed child within one year of placement;
• A serious health condition that makes the employee unable to             ☐               ☐
 perform the functions of their job;
• To care for the employee’s spouse, child or parent who has a 
serious health condition;
• Any qualifying exigency arising out of the fact that the employee’s 
spouse, child or parent is a military member on covered active duty
 (or call to covered active duty status); or
• To care for a covered service member with a serious injury or
 illness if the employee is the spouse, child, parent or next of kin of 
the service member.

If the employee has already used FMLA leave this year, does the
employee still have FMLA leave available?
Eligible employees are entitled to take up to 12 weeks of FMLA leave
during a 12-month period (26 weeks to care for a covered service 
member). To make this determination, confirm which 12-month period
(leave year) is used by your organization to calculate FMLA leave. An 

employer’s options for the leave year are:
• The calendar year (Jan. 1 through Dec. 31)                                                    ☐            ☐
• Any fixed 12-month period, such as a fiscal year or a leave year
beginning on the first day of an employee’s employment
• A 12-month period measured forward from the first date an
employee takes FMLA leave; or
• A rolling 12-month period measured backward from the date
an employee uses FMLA leave.

If you answered “no” to any of the questions above, the employee is not eligible to take leave under the FMLA. Provide the employee with a Notice of Eligibility and Rights & Responsibilities (Form WH-381) and a Designation Notice (Form WH-382) within five business days of the employee’s request for leave, indicating that the employee is not eligible for FMLA leave. Also, consider whether the employee is eligible for leave under any other employer leave policy or federal, state or local law.

Did the employee provide sufficient advance notice of their need
to take FMLA leave?
Generally, an employee must give at least 30 days advance notice
of the need to take FMLA leave when they know about the need
for the leave in advance and it is possible and practical to do so.
If an employee does not provide at least 30 days advance notice,
but it was possible and practical to do so, the employer may delay
the FMLA leave until 30 days after the date the employee provides            ☐          ☐
 the notice.

When the need for leave is unexpected, the employee must provide
notice as soon as possible and practical. It should usually be
reasonable for the employee to provide notice of leave that is 
unforeseeable within the time required by the employer’s usual and
customary notice requirements.

Processing Leave Requests

                  Leave Request Process                                                Complete              Deadlines

Provide the Notice of Eligibility and Rights & 

Responsibilities within five business days of the 
employee’s request for leave unless there are extenuating

circumstances                                                                                          ☐                  Date notice is      The U.S. Department of Labor (DOL) has a model form                                            provided:
(Form WH-381) that employers may use for this notice
 requirement.

If a certification is required for the requested leave, give
the appropriate form to the employee and provide the
employee with at least 15 calendar days to return the form.

An employer may require a medical certification when leave
is requested for the employee’s own serious health condition
or the serious health condition of a family member.                                                    Date
Employers can also require a certification for military family/                             certification
caregiver leave. The DOL has the following model forms that                              form is due:
employers may use for obtaining certifications:

• Certification for employee’s serious health condition
 (Form WH-380-E);       

• Certification for family member’s serious health condition          ☐
 (Form WH-380-F);             
• Certification for military family leave— qualifying exigency                                     Date
 (Form WH-384);                                                                                                              certification
• Military caregiver leave of a current service member                                                form is

 (Form WH-385); and                                                                                                       returned:
• Military caregiver leave of a veteran (Form WH-385-V).

An employee requesting FMLA leave should be informed of this
certification requirement in the Notice of Eligibility and Rights &
Responsibilities, and the appropriate certification form should be
provided.

If FMLA leave will be approved, determine whether paid leave
will be used at the same time as FMLA leave.

An eligible employee may choose or an employer may require
the employee to substitute accrued paid leave for FMLA leave.
“Substitute” means that the accrued paid leave will run concurrently
with the unpaid FMLA leave. When an employee chooses or an
employer requires the substitution of paid leave, the employer must                    ☐
inform the employee of any procedural requirements of the
employer’s paid leave policy that the employee must satisfy. If the
employee does not comply with those procedural requirements, the
employee is no longer entitled to substitute accrued paid leave but
remains entitled to take unpaid FMLA leave.

If a certification is required for the leave, review any certification
form returned by the employee to determine whether it has been                        ☐
appropriately completed.

If a certification is incomplete or insufficient, notify the employee
about what additional information is needed to complete the
certification form.

Employers use the Designation Notice to inform an employee
that the certification is incomplete or insufficient and identify                               Date notice is
what information is needed to make the certification complete                               provided:
and sufficient.

• A certification is considered incomplete if one or more
applicable entries have not been completed; and
• A certification is considered insufficient if the information                     ☐
provided is vague, ambiguous or nonresponsive.

An employee must have at least seven calendar days to correct
any deficiency in the certification. If it is not practicable under                               Deadline for
the circumstances for the employee to cure any deficiency in the                          providing more
seven-day period despite their good-faith efforts, the employer                              information:
should provide additional time. If an employee fails to provide a
complete and sufficient certification despite the opportunity to 

cure the deficiency, an employer may deny the employee’s request
for FMLA leave.

Request second and third medical certifications, if needed.

If an employer has received a complete and sufficient certification
but has a reason to doubt that it is valid, the employer may require
the employee to obtain a second opinion at the employer’s expense.
If the first and second opinions reach different conclusions, the                            Date of
employer may require a third opinion at the employer’s expense.                           request:
The opinion of the third health care provider is final.                                  ☐

While waiting for the second (or third) opinion, the employee is                             Date medical
temporarily entitled to FMLA leave, including the right to maintain                        opinion(s) are
their group health benefits. If the certifications do not ultimately                           provided:
establish that the employee is entitled to FMLA leave, the leave
is not considered FMLA leave and may be treated as paid or
unpaid leave under the employer’s established leave policy.

Grant or deny the FMLA leave by providing the Designation
Notice in a timely manner.

This notice must be provided once the employer has enough
information to determine if the employee’s requested leave
qualifies as FMLA leave, as follows:

• If a certification is not required for the requested leave,
provide the Designation Notice within five business days of the
leave request; or
• If a certification is required, provide the Designation Notice
within five business days of when the employee submits a
complete and sufficient certification form.

The DOL has a model Designation Notice (Form WH-382)                      ☐             Date notice is 
employers may use.                                                                                                             provided:

The employer is responsible in all circumstances for designating
leave as FMLA-qualifying and giving a Designation Notice to the
employee. Note that leave taken under a disability leave plan or
as a workers’ compensation absence that also qualifies as FMLA
leave due to the employee’s own serious health condition may be
designated by the employer as FMLA leave and counted against
the employee’s FMLA leave entitlement.

Failure to provide a timely Designation Notice to an employee may
be considered interference with, restraint or denial of the exercise
of the employee’s FMLA rights.

Administering FMLA Leaves

                                  FMLA Obligations                                                                    Complete

During leave, maintain coverage under the group health plan on
the same basis as coverage would have been provided if the
employee had been continuously employed during the entire
leave period.                                                                                                                      ☐

During the FMLA leave period, an employee must continue to pay
whatever share of group health plan premiums the employee paid
prior to FMLA leave. The employer must provide the employee with
advance written notice of the terms and conditions under which
these payments must be made.

If applicable, the employee must provide a fitness-for-duty
certification to show that they can resume work after taking a leave
for their own serious health condition.                                                                        ☐

Employers may have a uniform policy requiring all similarly situated
employees who take leave for serious health conditions to provide a
fitness-for-duty certification.

Restore the employee to the same job (or an equivalent job) at the                  
end of the leave.                                                                                                              ☐

The employee is not guaranteed the actual job they held prior to the
leave. An “equivalent job” means a job that is virtually identical to the
original job in terms of pay, benefits, and other employment terms
and conditions (including shift and location). 

Maintain records regarding FMLA leave for at least three years.

Covered employers who employ FMLA-eligible employees must

maintain records that include the following:
• Basic payroll and identifying employee data;
• Dates FMLA leave is taken (which must be designated in the
• Copies of FMLA notices provided by an employee to the employer                   ☐ 
and by the employer to its employees concerning the FMLA
(including any written request for leave from the employee as well
as any required notice provided to the employee concerning FMLA
leave);

• Hours of FMLA leave used if leave is taken in increments of less
than a day;
• Any documents, including electronic records, describing employee
benefits or employer policies and practices regarding the taking of
paid or unpaid leave;
• Premium payments for employee benefits; and
• Records of any dispute between the employer and an employee
regarding the designation of leave as FMLA leave, such as emails or
other written statements regarding a disagreement on the
designation of the employee’s FMLA leave request.    

Maintain FMLA medical certifications as confidential medical records.

These records must be maintained in separate files from the usual
personnel files. As medical records, they are subject to confidentiality              ☐
requirements of the Americans with Disabilities Act and the Genetic
Information Nondiscrimination Act, as applicable. 

Use this checklist as a guide when reviewing your company’s compliance with processing an employee’s FMLA leave request. For assistance, contact The Complete Manager Makeover Membership.

This checklist is merely a guideline. It is neither meant to be exhaustive nor meant to be construed as legal advice. It does not address all potential compliance issues with federal, state or local standards. Consult your licensed representative at The Complete Manager Makeover Membership or legal counsel to address possible compliance requirements