W/FMLA - RELATED FORMS

 


Employee Request for Family and/or Medical Leave (UWS 80) - employee completes this form to request W/FMLA-protected leave. An employee who requests a WFMLA leave to care for a domestic partner or a domestic partner's parent must complete this form in order to certify the domestic partnership for WFMLA purposes.

Notice of Eligibility and Rights & Responsibilities
(UWS 81) - employer gives this completed form to the employee to inform the employee of eligibility to use W/FMLA leave, to outline any information needed by the employee to certify the reason for leave and to notify the employee of rights and responsibilities.


Certification by Health Care Provider for Employee's Serious Health Condition (UWS 82) - employee's health care provider must complete this form to certify the employee's serious health condition if an employee is taking a concurrent FMLA and WFMLA leave. Note regarding employees who take a WFMLA leave only - If an employee is taking a WFMLA only leave (employee does not qualify for federal FMLA), the employee should use the WFMLA compliant form, UWS 82a, to certify his or her own serious health condition.

Certification by Health Care Provider for Family Member's Serious Health Condition
(UWS 83) -the employee's family member's health care provider must complete this form to certify the family member's serious health condition if an employee is taking a concurrent FMLA and WFMLA leave. Note regarding employees who take a WFMLA leave only - If an employee is taking a WFMLA only leave (employee does not qualify for federal FMLA and/or the employee is taking a leave to care for a domestic partner or a domestic partner's parent), the employee should use the WFMLA compliant form, UWS 83a, to certify a family member's serious health condition.

Certification of Qualifying Exigency for Military Family Leave (UWS 84) - an employee must complete this form to certify the exigency that was created because a family member was called to active military duty from a reserve status.

Certification of Serious Injury or Illness of Covered Servicemember for Military Leave (UWS 85) - an employee must complete this form if the employee wants FMLA-protected leave to care for a covered military servicemember who is a family member or next of kin and who is seriously ill or injured due to military service

Designation Notice (UWS 86) - employer gives this completed form to the employee who has requested a W/FMLA-protected leave to let the employee know if the leave is approved and/or if the employee needs to submit any additional information before the leave can be approved.