(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 ____________________:

We have received your request dated ____________ to take time off from work under 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 health-care 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 form no later than thirty days prior to the first day you are requesting leave. However, if your leave has been foreseeable for less than thirty days, please fill out and return the form immediately.

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.

The Notice and the copy of the company's FMLA policy are for you to keep for your records. It is recommended that you make a copy of your FMLA request form or ask us to make a copy for you when you turn it in. All of the information in the Notice is important. However, please pay extra attention to the section about the continuation of your medical benefits and the use of your accrued paid time off.