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Letter to an Employee Who May Be Eligible for FMLA


[Employee name]



Dear [Employee name]:

On [date], we became aware that you have been absent from work under circumstances that may qualify for leave under the Family and Medical Leave Act (FMLA). The purpose of this letter is to provide you with information and the forms both you and your health care provider need to complete and return to us so that we may determine if your absence(s) may be designated as FMLA leave.

You will find enclosed the FMLA Notice of Eligibility and Rights & Responsibilities and [company name]'s FMLA policy. Please review closely and retain both the notice and our policy.

The following FMLA forms are enclosed:

Employee Request for FMLA Leave: You will need to complete this form and return it to us as soon as possible. A return envelope is enclosed.

Certification of Health Care Provider: You will need to give this form to your health care provider for completion. Your health care provider may return the completed form directly to us (using the enclosed return envelope) or to you for submission. Please be sure that this completed form is returned to us within 15 days of this letter or provide us with a reasonable explanation for the delay. Failure to provide certification may result in a denial of continuation of leave. As stated in our FMLA policy, medical information received for FMLA leave is considered confidential and shall be disclosed only to those involved in the FMLA leave determination.

After receipt and review of these two forms, we will make a determination on the designation of your absence as FMLA leave. If you have any questions or would like more information on FMLA leave, please contact [name, phone number].




[HR employee name]

[Job title]



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