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Family Medical Leave Act

The Family Medical Leave Act (FMLA) entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. Eligible employees are entitled to twelve workweeks of leave in a 12-month period for:

• The birth of a child and to care for the newborn child within one year of birth.
• The placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement.
• To care for the employee’s spouse, child, or parent who has a serious health condition.
• A serious health condition that makes the employee unable to perform the essential functions of his or her job.
• Any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on covered active duty.
• Twenty-six workweeks of leave during a single 12-month period to care for a covered service member with a serious injury or illness if the eligible employee is the service member’s spouse, son, daughter, parent, or next of kin (military caregiver leave).

Forms

1. Employee Health Condition
   • Authorization for Release of Information (HIPPA Form)
   • Certification of Health Care Provider for Employee’s Health Condition
2. Family Member Health Condition
   • Certification of Health Care Provider for Family Member’s Health Condition
   • Affidavit of Family Relationship
   • Authorization for Release of Information (HIPPA Form)
   • Addendum for Child 18 Years or Older
3. Military Family Leave
   • Certification for Serious Injury or Illness of a Current Servicemember for Military Caregiver Leave
   • Certification for Military Family Leave for Qualifying Exigency
   • Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave
   • Employee Guide to Military Family Leave
4. Care and Bonding Request
5. Release to Work Form
6. Employee Rights Under the Family and Medical Leave Act
7. Nevada Pregnant Workers’ Fairness Act
8. Personnel Directive No. 15 – The Family and Medical Leave Act

Instructions

1. Employee Notice Requirements for Foreseeable FMLA Leave
2. File FMLA claims using AbsenceSoft, which can be accessed through My ESS
3. AbsenceSoft User Instructions
4. AbsenceSoft Quick Guide

For more information, visit U.S. Department of Labor FMLA Overview. All other forms can be download by visiting Nevada Attendance and Leave Forms (nv.gov) or the U.S. Department of Labor website.

Contact Risk Management at Phone: 702-455-4544 Fax: 702-455-3084 Email: FMLAInquiries@ClarkCountyNV.gov