(For your convenience, you may download Forms WH-380 and WH-381 from the Dept. of Labor Web site. Use of the forms is optional, but the relevant information must be given to the employee in a written format.)

Date:

Employee Name:

Address:

City/State/Zip:

Dear ____________________:

You have not reported to work on ____________. We became aware that your absence may be due to circumstances that may qualify for leave under the Family and Medical Leave Act (FMLA).

I have enclosed a copy of our FMLA policy along with forms for both you and your healthcare provider to fill out and return. An FMLA Employer Response to Employee Request for FMLA Leave (Form WH-381) is also enclosed. This serves as your notice of FMLA regulations, your rights, and the obligations and expectations of you during leave. You will be notified in writing about the status of your leave request.

Please fill out and return the enclosed Employee's Request for Family and Medical Leave at your earliest convenience. This form is to be completed no later than thirty days before the start of a leave that is foreseeable. Since there has been no advance notice of your absence, we ask that you fill it out as soon as possible.

The Certification of Health Care Provider (WH-380) form is for your health-care provider to complete and return. The form may be returned to you or mailed directly to us. I have enclosed a return envelope for your provider's convenience. Please follow up with us to ensure that we have received the completed form from your health-care provider within fifteen days of the request. If there is a delay, your condition or situation will not be certified and this may result in the discontinuation of your leave. As stated in our enclosed copy of the FMLA policy, your medical-certification paperwork is considered confidential and will be viewed only by the person(s) involved in approving your FMLA leave.