(Employers — note that your policy or state regulations may be different than the information provided in this sample.)

This written notice highlights the FMLA policy at ABC company.

Employees who have been employed for at least twelve months and worked at least 1,250 hours in that year are entitled to twelve weeks of unpaid leave under the Family and Medical Leave Act of 1993. Time worked is considered hours designated by the Fair Labor Standards Act (FLSA).

FMLA may be requested due to the birth or placement of a child with you for adoption or foster care, during your own serious health condition that makes you unable to perform the essential duties of your job, or during the serious health condition of an immediate family member that requires your care. The immediate family members who qualify are your spouse, child, or parent.

Employees are to notify the company verbally or in writing that they are requesting a leave of absence. If the leave is believed to be one that qualifies for FMLA, the appropriate packet of paperwork will be forwarded to the employee within two days.

You have a right under the FMLA for up to twelve weeks of leave with job protection in a twelve-month period during a qualifying event. This company recognizes a rolling twelvemonth period. This means that the company takes the last date of FMLA leave used and counts forward twelve months to determine if unused leave is available.

The job protection provided to employees under the FMLA requires reinstatement into the same job upon return, or a job with substantially similar pay, duties, status, hours, and working conditions.

Our policy requires employees to use accrued sick leave while they are on FMLA. Sick leave is to be used at the beginning of the leave until exhausted. Vacation leave or personal leave may be used at the employee's discretion. The payroll department must be advised of an employee's desire to use accrued vacation or personal leave during this time.

Once an employee's paychecks stop while they are on leave (after the usage of sick leave), employees are required to pay their usual premiums for health insurance. The human resources office will advise employees of the amount due. Payments are due at the first of the month for the month of payment (for example, the insurance due on May 1 is for insurance premiums for the month of May).