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FMLA Leave Tracking Form

This document is an HR form used to record FMLA leave for monthly paid employees. It requires employees to provide information such as name, dates of leave, type of leave, and signatures for approval. The business office then enters the FMLA time used into the system.

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22 views1 page

FMLA Leave Tracking Form

This document is an HR form used to record FMLA leave for monthly paid employees. It requires employees to provide information such as name, dates of leave, type of leave, and signatures for approval. The business office then enters the FMLA time used into the system.

Uploaded by

Milin Anik's
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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HR FORM 33FMLA – (Revised 2/14) Select One: New Revised

RECORD OF FMLA LEAVE FOR MONTHLY-PAID EMPLOYEES


Employee: Use this form to document FMLA usage. Complete Sections 1 and 2, sign and route the form for approval
signatures (Section 3). NOTE: This approved form must be received by the Business Office/Time Administrator
on a weekly basis or as the FMLA time is used.

Business Office/Time Administrator: Enter FMLA time used into CATS as soon as form is received & forward to
HRSC/FREH or regional campus HR for processing.
Section 1. COMPLETED BY EMPLOYEE (Consult with Business Office or HRSC, (765) 494-2222, if
information is not known.)

A. Name: D. PERNR:
B. Org Unit
Name: E. CUL:
C. Org Unit
Number:

FMLA From To Pay Usage Leave FMLA FMLA Usage

Leave (Start (End Date) (See list Pay C Continuous Leave Record Hours
Date) (MM/DD/YY) below) (100% INT Intermittent Leave-Recorded
(MM/DD/YY) or in hours per day-each day separate
Taken
75%) line.

RS Reduced Schedule Leave
Line 1
Line 2
Line 3
Line 4
Line 5
Additional dates included on attached spreadsheet or additional HR Form 33FMLA

PAY USAGE
FMH FMLA Using Paid Holiday FMV FMLA Using Vacation
FMPB FMLA Using Personal Business Day FMPL FMLA Using Paid Parental Leave
FMSE FMLA Using Sick Leave—Employee FMUP FMLA Unpaid Leave
FMSF FMLA Using Sick Leave – Family

Section 2. ADDITIONAL COMMENTS (Optional)

Section 3. SIGNATURES

______________________________ ___________________ ___________________________________ ____________________


Employee Signature Date Supervisor Signature Date
______________________________ ____________________

Business Office Signature Date

BUSINESS OFFICE/HUMAN RESOURCES USE ONLY

This form due to the Business Office/Time Administrator on a weekly basis or as the FMLA time is used.
Original retained in employee’s confidential FMLA leave file.

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