Family and Medical Leave Act (FMLA) Forms Archives - OCWR

Home Family and Medical Leave Act (FMLA) Family and Medical Leave Act (FMLA) Forms

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Form F – Certification for Serious Injury or Illness of a Current Servicemember – for Military Family Leave

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<img width="360" height="180" src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image" alt="paper icon, with title of article" decoding="async" srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" sizes="(max-width: 360px) 100vw, 360px" />

Form C – Notice of Eligibility Rights and Responsibilities

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<img width="360" height="180" src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image" alt="paper icon, with title of article" decoding="async" srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" sizes="(max-width: 360px) 100vw, 360px" />

Form D – Designation Notice

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<img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image" alt="paper icon, with title of article" decoding="async" loading="lazy" srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" sizes="(max-width: 360px) 100vw, 360px" />

Form E – Certification of Qualifying Exigency for Military Family Leave

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<img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image" alt="paper icon, with title of article" decoding="async" loading="lazy" srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" sizes="(max-width: 360px) 100vw, 360px" />

Form A – Certification of Health Care Provider for Employee’s Serious Health Condition

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<img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image" alt="paper icon, with title of article" decoding="async" loading="lazy" srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" sizes="(max-width: 360px) 100vw, 360px" />

Form B – Certification of Health Care Provider for Family Member’s Serious Health Condition

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<img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" data-src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image lazyload" alt="paper icon, with title of article" decoding="async" loading="lazy" data-srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" data-sizes="(max-width: 360px) 100vw, 360px" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" style="--smush-placeholder-width: 360px; --smush-placeholder-aspect-ratio: 360/180;" /><noscript><img width="360" height="180" src="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png" class="attachment-archive-posts-thumbnail size-archive-posts-thumbnail wp-post-image" alt="paper icon, with title of article" decoding="async" loading="lazy" srcset="https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-360x180.png 360w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-300x150.png 300w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1024x512.png 1024w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-768x384.png 768w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image-1536x768.png 1536w, https://www.ocwr.gov/wp-content/uploads/2019/06/FMLA-ft-image.png 1800w" sizes="(max-width: 360px) 100vw, 360px" />

Form G – Certification for Serious Injury or illness of a Veteran for Military Caregiver Leave