Disability and Leave Forms and Letter Descriptions

Descriptions by Topic

Disability Forms and Letters
Leave Forms and Letters
Leave - Health Certification Forms
Leave - Exhaustion Letters
Return to Work Forms and Letters
General Forms

Disability Forms and Letters

IDAD - Interactive Disability Accommodation Document

The IDAD is completed at the completion of the interactive process by the department to record a reasonable accommodation offered by the employer. The employee indicates agreement or disagreement and may complete an Accommodation Review Request Form if the accommodation offered does not accommodate health limitations. After signatures are obtained, a copy of the IDAD is forwarded to FSDS.

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MIRF Letter

The Medical Information Request letter should be sent to an employee when a health limitation is disclosed and the department does not have sufficient information to determine the limitation(s) impact on work.

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MIRF - Medical Information Request Form and Release of Information

The form (MIRF) should be sent to an employee in conjunction with the MIRF letter and is completed by the employee's treating health provider for the health condition’s limitations in question. A release of information is enclosed to provide consent for FSDS staff to communicate with the THP if the returned documentation is insufficient to determine workplace needs. The completed MIRF is to be forwarded to FSDS for implementation of the interactive process, as applicable.

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Release of Information Form

The Release of Information Form is used to give authorization for FSDS staff to contact treating health providers. This form is completed by the employee and the signature signing must be witnessed. The authorization is used by FSDS when medical information is insufficient to determine an employee's health limitation (s) and/or impact to the work environment or in FMLA situations when medical documentation was not cured in the additional seven days.

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Leave Forms & Letters

FMLA Eligibility Notice

The FMLA Eligibility Notice is sent to an employee notifying of eligibility status for FMLA. This form is sent within 5 business days of knowledge of potentially qualifying FMLA absence.

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FMLA Designation Notice

The FMLA Designation Notice is sent to an employee in notification of approval, denial, or insufficient information to determine FMLA eligibility. This form is sent within 5 business days of receipt of information regarding absences considered for FMLA.

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Adult Child FMLA Eligibility Letter

The Adult Child FMLA Eligibility Letter is sent to an eligible employee who seeks absence from work to care for a child 18 years and older. This letter is sent in conjunction with the FMLA Eligibility Form.

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Adult Child FMLA Eligibility Form

The Adult Child Eligibility Form is sent in conjunction with the Adult Child FMLA Eligibility Letter, and is completed by the child's treating health provider. The department is to contact FSDS to determine if the adult child’s needs meet FMLA criteria.

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Non-FMLA Continuous Medical Leave Request Letter

The Non-FMLA Leave Request letter is sent to an employee when the employer has knowledge of need for continuous absence not eligible for FMLA is not available. This letter is sent in conjunction with the Non-FMLA Leave Request Form.

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Non-FMLA Continuous Medical Leave Request Form

The Non-FMLA Leave Request Form and Release of Information is sent in conjunction with the request letter, and is completed by the treating health provider to indicate medical necessity of a continuous leave. A release of information is enclosed to provide consent for FSDS staff to communicate with the THP if the returned documentation is insufficient to determine workplace needs.

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Confirmation of FMLA Intermittent Absence Exceeding Approval Letter

This letter is sent to an employee when treating health provider confirmation is required to consider authorization of absences exceeding original intermittent FMLA approval. The first occasion of overuse should include a conversation with the employee and absence should be approved if reasonably explained. This letter is used on the second occasion of overuse. Without additional information, further absences in excess of original designation will not be authorized as FMLA. 

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Leave - Health Certification Forms

FMLA Self Health Certification Form

The FMLA Self Health Certification Form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee may need to be absent from work due to his/her own health, and the employer does not have sufficient information to determine absence eligibility. The treating health provider of the health condition completes this form.

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FMLA Family Health Certification Form

The FMLA Family Health Certification Form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to an eligible family member's health and the employer does not have sufficient information to determine absence eligibility. The treating health provider of the family member's health condition completes this form.

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FMLA Military for Serious Injury or Illness of Covered Servicemember Form

The form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to an eligible military family member injury, and the employer does not have sufficient information to determine absence eligibility for FMLA. The Department of Defense or the treating health provider of the health condition completes this form.

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FMLA Military for Serious Injury or Illness of a Veteran or Military Caregiver Leave

The form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to care for a family member who is a covered veteran with a serious injury or illness, and the employer does not have sufficient information to determine absence eligibility. The form is completed by the Veteran's treating health provider.

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FMLA Military Family Leave - Qualifying Exigency Certification Form

The FMLA Certification of Qualifying Exigency for Military Family Leave Form is sent to an employee in conjunction with the FMLA Eligibility Notice, when an eligible employee seeks absence from work due to military family member's deployment and the employer does not have sufficient information to determine absence eligibility. The form is completed by the employee.

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Leave - Exhaustion Letters

FMLA Exhaustion and Following Status Letter

The FMLA Exhaustion letter should be sent to an employee when calendar year FMLA is anticipated to exhaust within 4-6 weeks and information is necessary to determine needs beyond FMLA. If a Release to Return was requested at FMLA designation; enclose a Release to Return to Work Form if the employee is currently absent, as well as a non-FMLA Leave Request Form if the employee has or will exhaust paid leave before anticipated return date. Enclose a Medical Information Request Form if the employee is currently working and the employer has knowledge of limitations impacting his/her ability to attend work. Include FSDS in communication regarding knowledge of need for non-FMLA unpaid leave.

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Non-FMLA Unpaid Medical Leave Exhaustion and Following Status Letter

The letter should be sent to an employee 4-6 weeks prior to exhaustion of approved, non-FMLA unpaid medical leave and knowledge of return or continued need for leave is necessary. Enclose a Release to Work Form, EMJFA, and non-FMLA leave Request Form.

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Return to Work Forms and Letters

Release to Work Letter

The letter should be sent to an employee when the employer has determined that more sufficient medical information is necessary for the employee to return to work following an absence. The letter should be used following hospitalization, for absences of more than two weeks, when an employee may be infectious, when the employer has knowledge of limitations/restrictions and/or has safety concerns. The Release to Work Form is sent in conjunction with this letter.

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Release to Work Form

The Release to Work Form should be sent in conjunction with the Release to Work Letter, or included as a separate document in exhaustion letters. This Form should be used following hospitalization, for absences of more than two weeks, when an employee may be infectious, when the employer has knowledge of limitations/restrictions and/or has safety concerns. If a release is required for an employee returning from FMLA, the employee must be notified of the requirement via the Designation Notice. The Release to Work Form is to be included in the notification.

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Temporary Restricted Work Plan Letter

The Temporary Restricted Work Plan letter may be used to record an employer's ability to provide work within minor/transitory restrictions of less than one to two months, restricted work hours if paid leave exists, and the restrictions are related to a non-occupational health condition. If restrictions exceed minor/transitory definition, see FSDS website to begin the interactive process.

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