HealthSource Medical Associates - FMLA Certification Eligibility

To qualify for FMLA leave, the following three criteria must be met:

1. You must meet certain employment criteria

2. Your employer must meet FMLA coverage criteria

3. You must have a condition that qualifies for FMLA leave.

You only qualify for FMLA leave if ALL THREE criteria are met.

Note: Qualifying for FMLA does not necessarily guarantee that FMLA leave will be approved by your employer.

Let's begin by making sure you meet basic employment criteria to be considered for FMLA leave.

First Name*

Last Name*

Primary Email*

Employer Name*

Have you been at your present job for at least 12 months?*

Yes

Have you worked at least 1250 hours (on average >24 hours/week) at your present job for the past 12 months before the start of your leave?*

Yes

Do you work at a location where your employer has at least 50 employees within a 75-mile radius?*

Yes

Is your employer a private sector company who employs 50 or more employees in 20 or more workweeks in either the current or previous calendar year?*

Yes

Is your employer a public agency such as Federal, State, or local government?*

Yes

Are you employed by a local educational agency (local public school board, public elementary and secondary school, private elementary, or secondary school)?

Yes

Please select which of the following is applicable to your reason for needing leave:*

I am currently pregnancy and needing maternity leave

I am expecting the birth of a child and need paternity leave

I am currently adopting a child

I am currently receiving a child placed through foster care

I need to care for my spouse, child, or parent who has a "serious health condition"

I have/had what I believe to be a "serious health condition" preventing me from performing work responsibilities

None of these are applicable to my condition

Please provide further information to determine if your condition meets criteria for a "serious medical condition" according to FMLA.*

I or my spouse/family member was recently hospitalized for this condition

I or my spouse/family member was placed in hospice for this condition

I or my spouse/family member was in a residential medical care facility (nursing home) for this condition

I or my spouse/family member am/is requiring treatment by a healthcare provider for this condition

I or my spouse/family member was incapable of working for at least three consecutive calendar days due to this condition

I or my spouse/family member was examined by a health provider for this condition and have received prescriptions or other orders for treatment

None of these are applicable to my condition

Thank you. Based on your responses, it does not appear that you are currently eligible for FMLA leave. To view the Department of Labor's website for further details regarding FMLA eligibility click here.