Family Medical Leave of Absence

Employee Self Service

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If you need to miss work related to a serious medical condition for yourself, spouse, child up to age 18, or parent you are required to apply for a Family Medical Leave.

Basic Leave Entitlement

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:

  • Incapacity due to pregnancy, prenatal medical care or child birth
  • To care for the employee’s child after birth, or placement for adoption or foster care
  • To care for the employee’s spouse, son or daughter up to age 18, or parent, who has a serious health condition
  • For a serious health condition that makes the employee unable to perform the employee's job

Employee Responsibilities

Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures.

Minimum Eligibility Requirements

An employee is eligible if they satisfy the following:

  • Has been employed at NHRMC for at least twelve (12) months (the months do not have to be consecutive)
  • Has worked at least 1250 hours during the twelve (12) month period prior to the time the leave would begin. Hours are calculated based upon actual hours that the employee worked, including overtime.


FMLA allows you to take leave for a temporary period of time up to 12 weeks per rolling calendar year. Approved FMLA prevents a loss of benefits and allows for job protection while you are out of work for up to 12 weeks.


Intermittent-FMLA can be taken for a personal illness or to care for a sick family member for occasional time off over a period of time determined by the physician. This periodic type of leave can NOT exceed more than 3 scheduled work days in a row.

Spousal Exception

If a husband and wife both work for NHRMC, and are eligible for leave, they are entitled to a combined 12 work weeks of leave taken for birth, adoption, foster care, or to care for a parent.

Procedures for Requesting FMLA 

  • You are required to notify your immediate supervisor of the leave request and obtain the appropriate forms to apply for a leave. It is your responsibility to complete and return all required paperwork to your HR Benefits Administrator to determine your leave eligibility. Failure to do so may result in the denial of your leave request.
  • Print the FMLA Medical Request Response Form and relevant Certification of Healthcare Provider form (Employee’s Serious Health Condition or Care of a Family Member with a Serious Health Condition)
  • Complete the FMLA Medical Request form including the effective date of leave and estimated return to work date. Intermittent requests cannot be submitted until you experience your first occasion of missed work. Use the above definitions to determine if your request is Traditional or Intermittent FMLA.
  • Give the Certificate of Healthcare Provider form to the Physician to complete based on the medical condition and the need for you to be out of work during the time period listed on your request. These dates must match the Certification of Healthcare Provider form.
  • Completed forms must be submitted to HR within 15 days of your first day out of work or within 30 days of a foreseeable leave request.