Sample Policy: FMLA

The following sample policy was excerpted from The Book of Company Policies, published by HR Specialist, © 2007. Edit for your organization’s purposes.


“FMLA-eligible employees may take unpaid leaves of absence for the following reasons:

Family leave: The birth of your child or the placement of a child in your home for adoption or foster care. FMLA family leave must conclude within 12 months after the birth or placement of your child.

Medical leave for yourself or family care: A serious medical condition of yourself or a family member (child, spouse, parent or one who stood in place of a parent).

A serious health condition is an illness, injury, impairment or physical or mental condition that involves inpatient care, treatment or supervision by a health care provider. A serious health condition includes any period of incapacity due to pregnancy or for prenatal care.

FMLA Compliance D

“Any paid leave to which the employee is entitled at the time of the leave must be taken as part of the 12-week leave, with the remainder of the leave unpaid. In other words, if the employee is entitled to two paid weeks of vacation plus five sick days when he or she goes on leave and takes the full 12 weeks off, the employee will be paid for the first three weeks of leave and take the remaining nine weeks without pay.

“You may take up to a total of 12 workweeks for family or medical leave in any 12-month period. A 12-month period is determined by reviewing the 12 months prior to the date the requested leave is to begin.

Eligibility: If you are an active employee, you are eligible for family and medical leave unless you have worked less than 1,250 hours during the 12-month period before the leave is to commence.

Procedures: After discussing your need for leave with your manager or supervisor, you should submit any request for an FMLA leave to the Human Resources Department at least 30 days prior to the date you wish to begin the leave if the need for leave is foreseeable. . . .

Medical certification: Employees taking FMLA medical leave for self or family care must submit a medical certification to Human Resources. XYZ may request, at its own expense, a second medical opinion. Should the first and second opinions differ, XYZ may require, at its own expense, the opinion of a jointly approved health care provider, whose opinion shall be binding. In addition, XYZ may periodically require recertification of a medical condition.

“In most cases, upon returning from FMLA medical leave for self-care, you will be required to provide medical certification that you are able to return to work. Requests for such certification will be job-related and consistent with the business necessity of XYZ.

Benefits and job continuation: All benefits, if you elect, will continue through the leave period. You must continue to contribute your share of any medical and insurance premiums. If you are using paid leave (i.e., vacation, sick leave, personal days) for your leave, you will continue to accrue vacation and sick leave, and you will be paid for holidays that occur during the paid portion of your leave. Vacation and sick leave will not accrue during any unpaid leave, and you will not be paid for holidays that occur during your leave. . . . When you return from FMLA leave, you will be restored to the same or an equivalent job position, unless your position has been affected by a reduction in force, reorganization or other change that would have occurred had you not been on leave.

“FMLA medical leave may be taken intermittently or on a reduced work schedule when medically necessary, subject to medical certification. In such circumstances, XYZ may temporarily transfer you to an alternative position for which you are qualified and that better accommodates the recurring periods of leave. If a transfer is made, your pay and benefits will not be reduced.”



Sample Letter: Notifying Employee of FMLA Leave

Dear :

Enclosed is an important notice regarding your leave of absence. The notice confirms that your leave will be counted against your annual allotment of leave under the Family and Medical Leave Act (FMLA).

The notice also provides additional information regarding your rights and responsibilities under the FMLA. Please pay special attention to those items that explain your obligations regarding continuation of benefits and your responsibility to provide with information about your leave. For example, to remain eligible for FMLA leave, you must furnish periodic certification from your health care provider of your need to take leave.

Additionally, we request that you give us permission to contact your health care provider so that we may clarify your certification of need for leave.

Please sign the enclosed permission form and return it to us in the enclosed envelope.

Thank you for your help. Please contact me if you have any questions.