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Document Information

Document Center includes the following documents and forms. Please review each type for important document and jurisdiction information (click on a link learn more).

Onboarding Documents

Leave Forms

 

Employment Application

Overview

The generated application includes content based on specific responses.  Because circumstances are different for each applicant, the application should be run for each applicant instead of trying to directly edit the Word document.

Important Information regarding EEO statement:

Job applications created by this program contain a statement describing the employer as an equal opportunity employer, and lists protected categories protected under federal laws. The laws in the states where the application may be used by the Company may include additional protected categories, which are referenced as “any other basis protected by applicable federal, state, and local laws.” Federal and state laws differ in terms of what size employers are covered by EEO laws. In other words, employers with a small number of employees (which is defined differently per jurisdiction) may or may not be subject to all anti-discrimination laws covered by this application. However, even if not subject to a particular law, an employer may still be subject to other types of claims or liability on the basis of discriminatory conduct, including claims based in public policy. Based on the complexity of this area of law, this program assumes that the employer meets the minimum employee thresholds and intends not to discriminate on the basis of any of the specifically listed classifications protected by federal laws:  race, color, sex, religion, national origin, age (40 and over), past or present military service, disability, and genetic information. Small employers using this program may therefore be assuming some risk by adopting a policy with protections that they are not legally required to provide.

Additionally, there may be situations where the Company decides to add protected categories not otherwise listed. Should you choose to add protected categories above and beyond what is included in the application, those should be selected carefully and the Company should select only those categories with which the Company is comfortable with possibly being bound.

If you have additional questions or are concerned about providing protections over the included categories, you should consult with experienced labor counsel for assistance.

This application does not address issues specific to posting an employment application in an electronic fashion or use of electronic signatures on an application.  This may or may not include additional language required based on the use of an electronic signature and additional requirements imposed by the OFCCP if the Company is a government contractor and uses an electronic job application.

This application does not address issues specific to federal contractors or employers utilizing an affirmative action plan. If you are a federal contractor, the OFCCP imposes additional disclosures and forms to be included with employment applications not included in this application.

Some employers may wish to ask a criminal history question during the hiring process, but given the EEOC’s position on criminal history inquiries and the wave of ban-the-box legislation being enacted at the state and local level, the questions concerning this topic have been excluded from this application at this time.

Drug testing and Physical Examination: Asking an applicant to undergo a drug test/physical exam may trigger additional authorizations or notice requirements above and beyond what is listed in this template application.  Additionally, there may be restrictions on timing and scope of such testing.  Make sure to check applicable legal requirements at the federal and state level.

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Work State Information

Select the state where the application will be used.

Connecticut
WARNING: Connecticut law prohibits employers from inquiring into the ages, dates of birth or dates of attendance/graduation at an educational institution, of prospective employees on an initial employment application except if the request is based on a bona fide occupational qualification or need, or if the employer needs the information to comply with applicable state or federal laws. Arguably, the purpose of asking if the applicant is at least 18 is not to identify the applicant’s age, but rather to ensure that the employer does not unknowingly hire a minor employee. However, the more cautious approach would be for a Connecticut employer to remove the question if it is not based upon a bona fide occupational qualification or need.

Delaware
WARNING: Delaware law prohibits employers from inquiring into the ages, dates of birth or dates of attendance/graduation at an educational institution, of prospective employees on an initial employment application except if the request is based on a bona fide occupational qualification or need, or if the employer needs the information to comply with applicable state or federal laws or the requirements of any regulatory, licensing or certifying body or organization. Arguably, the purpose of asking if the applicant is at least 18 is not to identify the applicant’s age, but rather to ensure that the employer does not unknowingly hire a minor employee. However, the more cautious approach would be for a Delaware employer to remove the question if it is not based upon a bona fide occupational qualification or need.

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Offer Letter

Overview

This letter template is not meant to be a comprehensive hire packet. It may touch upon notices required at hire, but make sure to still check state and local laws to ensure compliance with any specific requirements, including but not limited to complex requirements regarding drug-testing, background checks, use of artificial intelligence, data privacy, wage theft notices, benefits issues, non-compete and non-disclosure agreements, arbitration agreements, general wage notice requirements at the time of hire, and any notices required on the first day of work. Notices required during the interview process are not covered in this template.

States and local venues have differing requirements for the methods and frequency of paying employees. This offer letter does not analyze the legality of a company’s chosen payment method. It also does not analyze whether an employee is properly classified as exempt/non-exempt.

Please utilize Risk Center for a risk analysis of exemption status. See the hint text within the application for more information about what is not covered.

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Work State Information

Select the prospective employee's work state.

California
California requires an employer to provide non-exempt employee with a Wage Theft Prevention Notice upon hire. If you do not already have a Wage Theft Prevention Notice form, Division of Labor Standards Enforcement provides online model notices in several languages.

Colorado
In Colorado, the City of Denver requires that employers prominently display, in English and Spanish, a city-approved wage theft notice. Additionally, employers must ensure that each worker receives a notice in a language the worker may understand within the first month of employment. If display of a physical notice is not feasible, including situations when a worker does not have a regular workplace or job site, employers may provide the required information on an individual basis, in a worker’s primary language, in a physical or electronic form that is reasonably conspicuous and accessible.

District of Columbia
The District of Columbia requires an employer to provide employees with a Wage Theft Prevention Notice upon hire. If you do not already have a Wage Theft Prevention Notice form, DC gov provides online model notices in several languages.

Florida
In Florida, Pinellas County requires an employer to provide applicant with a Wage Theft Prevention Notice upon hire. If you do not already have a Wage Theft Prevention Notice form, the Pinellas County Office of Civil Rights provides online a notice template.

Minnesota
Minnesota requires an employer to provide applicant with a Wage Theft Prevention Notice upon hire. If you do not already have a Wage Theft Prevention Notice form, the Minnesota Department of Labor and Industry provides sample notices in several different languages. Minneapolis and St. Paul employers have additional notice requirements.

New Jersey
New Jersey requires an employer to provide applicant with a Wage Theft Prevention Notice upon hire. If you do not already have a Wage Theft Prevention Notice form, the New Jersey Department of Labor and Workforce Development will publish a model notice to be distributed to employees.

New York
New York requires an employer to provide applicant with a Wage Theft Prevention Notice upon hire. If you do not already have a Wage Theft Prevention Notice form, the New York State Department of Labor provides online model Wage Theft Prevention Act notices in several languages.

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Non-Disclosure Agreement

Overview

Nondisclosure and related restrictions are dense with difficult legal issues.  CHR works with subject matter experts in these areas to provide as much guidance as possible, but this area of law is both very nuanced and highly active.  If you are looking at generating a nondisclosure agreement, you need to be familiar with the area of law and the issues involved. Moreover, your company needs to be very careful and strategic with how these agreements are deployed; otherwise there could be significant fallout or substantial exposure for the organization. 

The agreement generated by this application does NOT include any of the following provisions:

  • Noncompete

  • Arbitration Agreement

  • Class Action Waiver

  • Jury Trial Waiver

  • Invention Assignment

  • Customer non-interference

  • Employee non-interference

This agreement also does not cover any industry or position-specific regulations on the use of noncompete agreements. This agreement is not intended for use with independent contractors.

Non-compete agreements are not appropriate in all situations and can lead to substantial exposure for your company unless they are deployed strategically. Document Center ensures that this document includes best-practice language, but the app does NOT evaluate whether your answers create an enforceable non-compete agreement. Properly scoping an enforceable non-compete agreement is a fact-specific undertaking, and it is a nuanced and frequently changing are of law.

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Work State Information

In what state does the Employee work?

Maine
WARNING. Maine law includes strict provisions for enforceable noncompetition covenants, including a minimum salary requirement and notice requirements.  An employer found violating these provisions may face a fine of not less than $5,000.

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Request for Leave

Overview

You can use this form to collect an employee's leave details when an employee tells their company about a need for leave.  This is not a mandatory form in the leave life-cycle, but can be very helpful to collect information necessary to process the leave request. You may still choose to complete the form for your records, even if it was not the method used by the employee to alert you that they need a leave of absence.

When to create this form:

  • The company should have received notice that the employee needs a leave of absence from work.

  • Please note that an employee who needs leave is not required to request “FMLA Leave” by name or to use a specific form to provide notice.  Any number of things can put an employer on notice, including the employee telling a manager or human resources, filling out a request form, or, in some cases, when the employee stops working.  If an employer has enough information to indicate that the reason for leave may qualify under the FMLA, then the employer is required to make the appropriate determinations under the FMLA and related state leave laws.

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Work State Information

Where does the Employee work?

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

California
Please note that employees in California may be eligible for wage replacement benefits under the State Disability Insurance law (Paid Family Leave). Employers cannot use this application to administer any part of the state disability insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

Connecticut
Please note that employees in Connecticut may be eligible for wage replacement benefits under the state Paid Family and Medical Leave Law (CT Paid Leave). Employers cannot use this application to administer any part of CT Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

Delaware
Please note that employees in Delaware may be eligible for paid leave under the Healthy Delaware Families Act (Delaware Paid Leave). Employers cannot use this application to administer any part of Delaware Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible (Nearly all employees, no matter employer size, will be eligible for paid leave rights if they spend at least 50% of their time working in D.C.) employees state-provided wage replacement benefits based on the employee’s weekly wages. The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance (TDI) law. Employers cannot use this application to administer any part of the TDI.  Employers must post notice of this law. See the Reference Center for more detail.

Maine
Please note that employees in Maine may be eligible for paid leave under the Maine Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Maryland
Please note that effective January 2028 (employees and employers will begin making contributions on January 1, 2027) employees in Maryland may be eligible for paid leave under the Family and Medical Leave Insurance law (Maryland FAMLI). Employers cannot use this application to administer any part of Maryland FAMLI. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption (An employer can apply to the state for an exemption from collecting, remitting, and paying PFML contributions.  The employer’s plan must provide benefits greater than or equal to the benefits provided by the PFML law, as well as provide the same rights and protections.). The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

Minnesota
Please note that employees in Minnesota may be eligible for paid leave under the Minnesota Paid Leave law (Minnesota Paid Leave). Employers cannot use this application to administer any part of Minnesota Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

New Jersey
Please note that employees in New Jersey may be eligible for wage replacement benefits under the state Temporary Disability and Family Leave Insurance law (TDI/FLI). Employers cannot use this application to administer any part of the TDI/FLI. Employers must post notice of this law. See the Reference Center for more detail.

New York
Nearly all (Employees who work 20 or more hours per week are eligible for leave after 26 weeks of employment.  Employees who work less than that are eligible for a prorated amount of leave after 175 days worked.) private employees in New York State are eligible for New York Paid Family Leave (PFL).  Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage (The number of weeks and amount of payment will increase every year until 2021, when eligible employees will be able to take up to 12 weeks of leave paid at 67% of their average weekly wage.}. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.  

New York State has developed a set of forms for employees and employers to use in order to administer PFL.  If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time.  If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app.  However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law (TDI). Employers cannot use this application to administer any part of TDI. Employers must post notice of this law. See the Reference Center for more detail.

Virginia
Please note that effective December 1, 2028 (employees and employers will begin making contributions on April 1, 2028) employees in Virginia may be eligible for paid leave under the state Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility (Employees needing medical leave for their own serious health condition, or family leave to care for a family member, to bond with a newborn or newly adopted child, or because of an military exigency can take up to 12 weeks of paid family and 12 weeks of medical leave,  for a combined total of 16 weeks of family and medical leave per claim year.   In addition, an employee can take two additional weeks of medical leave if the reason for leave is due to pregnancy complications.  An employer is required to provide an employee a Notice of Rights five business days after the employee's seventh consecutive day of absence due to family or medical leave, or within five business days after the employer has received notice that the employee's absence is due to family or medical leave, whichever is later.) and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers not be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Notice of Eligibility

Overview

This form informs the employee whether they are eligible for FMLA leave and provides the employee a notice of their rights and responsibilities.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company may have created a Leave of Absence Request form.

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Work State Information

Where does the Employee work? 

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

California
Please note that employees in California may be eligible for wage replacement benefits under the State Disability Insurance law (Paid Family Leave). Employers cannot use this application to administer any part of the state disability insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

Connecticut
Please note that employees in Connecticut may be eligible for wage replacement benefits under the state Paid Family and Medical Leave Law (CT Paid Leave). Employers cannot use this application to administer any part of CT Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

Delaware
Please note that employees in Delaware may be eligible for paid leave under the Healthy Delaware Families Act (Delaware Paid Leave). Employers cannot use this application to administer any part of Delaware Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible (Nearly all employees, no matter employer size, will be eligible for paid leave rights if they spend at least 50% of their time working in D.C.) employees state-provided wage replacement benefits based on the employee’s weekly wages. The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance (TDI) law. Employers cannot use this application to administer any part of the TDI.  Employers must post notice of this law. See the Reference Center for more detail.

Maine
Please note that employees in Maine may be eligible for paid leave under the Maine Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Maryland
Please note that effective January 2028 (employees and employers will begin making contributions on January 1, 2027) employees in Maryland may be eligible for paid leave under the Family and Medical Leave Insurance law (Maryland FAMLI). Employers cannot use this application to administer any part of Maryland FAMLI. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption (An employer can apply to the state for an exemption from collecting, remitting, and paying PFML contributions.  The employer’s plan must provide benefits greater than or equal to the benefits provided by the PFML law, as well as provide the same rights and protections.). The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

Minnesota
Please note that employees in Minnesota may be eligible for paid leave under the Minnesota Paid Leave law (Minnesota Paid Leave). Employers cannot use this application to administer any part of Minnesota Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

New Jersey
Please note that employees in New Jersey may be eligible for wage replacement benefits under the state Temporary Disability and Family Leave Insurance law (TDI/FLI). Employers cannot use this application to administer any part of the TDI/FLI. Employers must post notice of this law. See the Reference Center for more detail.

New York
Nearly all (Employees who work 20 or more hours per week are eligible for leave after 26 weeks of employment.  Employees who work less than that are eligible for a prorated amount of leave after 175 days worked.) private employees in New York State are eligible for New York Paid Family Leave (PFL).  Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage (The number of weeks and amount of payment will increase every year until 2021, when eligible employees will be able to take up to 12 weeks of leave paid at 67% of their average weekly wage.}. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.  

New York State has developed a set of forms for employees and employers to use in order to administer PFL.  If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time.  If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app.  However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law (TDI). Employers cannot use this application to administer any part of TDI. Employers must post notice of this law. See the Reference Center for more detail.

Virginia
Please note that effective December 1, 2028 (employees and employers will begin making contributions on April 1, 2028) employees in Virginia may be eligible for paid leave under the state Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility (Employees needing medical leave for their own serious health condition, or family leave to care for a family member, to bond with a newborn or newly adopted child, or because of an military exigency can take up to 12 weeks of paid family and 12 weeks of medical leave,  for a combined total of 16 weeks of family and medical leave per claim year.   In addition, an employee can take two additional weeks of medical leave if the reason for leave is due to pregnancy complications.  An employer is required to provide an employee a Notice of Rights five business days after the employee's seventh consecutive day of absence due to family or medical leave, or within five business days after the employer has received notice that the employee's absence is due to family or medical leave, whichever is later.) and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers not be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Employee Health Certification

Overview

This form can be used to collect information about an employee’s health condition.  It should be given to the employee, who provides it to their health care provider to complete.  The company can then use the information on the form to confirm that the employee is suffering from a serious health condition under FMLA and related state leave laws, and that the leave is protected under the law.  Failure to provide sufficient certification can be grounds to deny a leave of absence.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company created a Notice of Eligibility form. Please note that best practice is to send any necessary certification forms along with the Notice of Eligibility.

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Work State Information

Where does the Employee work? 

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

California
Please note that employees in California may be eligible for wage replacement benefits under the State Disability Insurance law (Paid Family Leave). Employers cannot use this application to administer any part of the state disability insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

Connecticut
Note that the employee’s inability to perform essential functions of the employee’s job is not applicable to CTFMLA.

Please note that employees in Connecticut may be eligible for wage replacement benefits under the state Paid Family and Medical Leave Law (CT Paid Leave). Employers cannot use this application to administer any part of CT Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

Delaware
Please note that employees in Delaware may be eligible for paid leave under the Healthy Delaware Families Act (Delaware Paid Leave). Employers cannot use this application to administer any part of Delaware Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible (Nearly all employees, no matter employer size, will be eligible for paid leave rights if they spend at least 50% of their time working in D.C. ) employees state-provided wage replacement benefits based on the employee’s weekly wages.  The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance (TDI) law. Employers cannot use this application to administer any part of the TDI.  Employers must post notice of this law. See the Reference Center for more detail.

Louisiana
PDL does not contain an affirmative provision allowing for certification, but does require the employee to provide reasonable notice.

Maine
Please note that employees in Maine may be eligible for paid leave under the Maine Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Maryland
Please note that effective January 2028 (employees and employers will begin making contributions on January 1, 2027) employees in Maryland may be eligible for paid leave under the Family and Medical Leave Insurance law (Maryland FAMLI). Employers cannot use this application to administer any part of Maryland FAMLI. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
MA does not have a mini-FMLA. As to the non-pregnant employee seeking time off under the MA Parental Leave Act, there is no requirement under the law that the pregnant spouse or partner (or the spouse/partner who just delivered the child) need care from the non-pregnant employee. The MA statute does not impose a care requirement.

The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption (An employer can apply to the state for an exemption from collecting, remitting, and paying PFML contributions.  The employer’s plan must provide benefits greater than or equal to the benefits provided by the PFML law, as well as provide the same rights and protections.). The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

Minnesota
Please note that employees in Minnesota may be eligible for paid leave under the Minnesota Paid Leave law (Minnesota Paid Leave). Employers cannot use this application to administer any part of Minnesota Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

New Jersey
Please note that employees in New Jersey may be eligible for wage replacement benefits under the state Temporary Disability and Family Leave Insurance law (TDI/FLI). Employers cannot use this application to administer any part of the TDI/FLI. Employers must post notice of this law. See the Reference Center for more detail.

New York
Nearly all (Employees who work 20 or more hours per week are eligible for leave after 26 weeks of employment.  Employees who work less than that are eligible for a prorated amount of leave after 175 days worked.) private employees in New York State are eligible for New York Paid Family Leave (PFL).  Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage (The number of weeks and amount of payment will increase every year until 2021, when eligible employees will be able to take up to 12 weeks of leave paid at 67% of their average weekly wage.}. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.  

New York State has developed a set of forms for employees and employers to use in order to administer PFL.  If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time.  If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app.  However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law (TDI). Employers cannot use this application to administer any part of TDI. Employers must post notice of this law. See the Reference Center for more detail.

Vermont
Note: Under Vermont law, an employer cannot require medical certification for parental leave (including leave during the pregnancy and following the birth of the employee’s child).

Virginia
Please note that effective December 1, 2028 (employees and employers will begin making contributions on April 1, 2028) employees in Virginia may be eligible for paid leave under the state Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility (Employees needing medical leave for their own serious health condition, or family leave to care for a family member, to bond with a newborn or newly adopted child, or because of an military exigency can take up to 12 weeks of paid family and 12 weeks of medical leave,  for a combined total of 16 weeks of family and medical leave per claim year.   In addition, an employee can take two additional weeks of medical leave if the reason for leave is due to pregnancy complications.  An employer is required to provide an employee a Notice of Rights five business days after the employee's seventh consecutive day of absence due to family or medical leave, or within five business days after the employer has received notice that the employee's absence is due to family or medical leave, whichever is later.) and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers not be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Family Health Certification

Overview

This form can be used to collect information about the family member’s health condition.  It should be given to the employee, who provides it to the family member’s health care provider to complete.  The company can then use the information on the form to confirm that the family member is suffering from a serious health condition under FMLA and related state leave laws, and that the employee’s caregiver leave is protected under the law. Failure to provide sufficient certification can be grounds to deny a leave of absence.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company created a Notice of Eligibility form. Please note that best practice is to send any necessary certification forms along with the Notice of Eligibility.

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Work State Information

Where does the Employee work? 

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

California
Please note that employees in California may be eligible for wage replacement benefits under the State Disability Insurance law (Paid Family Leave). Employers cannot use this application to administer any part of the state disability insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

Connecticut
Please note that employees in Connecticut may be eligible for wage replacement benefits under the state Paid Family and Medical Leave Law (CT Paid Leave). Employers cannot use this application to administer any part of CT Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

Delaware
Please note that employees in Delaware may be eligible for paid leave under the Healthy Delaware Families Act (Delaware Paid Leave). Employers cannot use this application to administer any part of Delaware Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

District of Columbia 
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible (Nearly all employees, no matter employer size, will be eligible for paid leave rights if they spend at least 50% of their time working in D.C.) employees state-provided wage replacement benefits based on the employee’s weekly wages. The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance (TDI) law. Employers cannot use this application to administer any part of the TDI.  Employers must post notice of this law. See the Reference Center for more detail.

Maine
Please note that employees in Maine may be eligible for paid leave under the Maine Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Maryland
Please note that effective January 2028 (employees and employers will begin making contributions on January 1, 2027) employees in Maryland may be eligible for paid leave under the Family and Medical Leave Insurance law (Maryland FAMLI). Employers cannot use this application to administer any part of Maryland FAMLI. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
MA does not have a mini-FMLA. As to the non-pregnant employee seeking time off under the MA Parental Leave Act, there is no requirement under the law that the pregnant spouse or partner (or the spouse/partner who just delivered the child) need care from the non-pregnant employee. The MA statute does not impose a care requirement.

The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption (An employer can apply to the state for an exemption from collecting, remitting, and paying PFML contributions.  The employer’s plan must provide benefits greater than or equal to the benefits provided by the PFML law, as well as provide the same rights and protections.). The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

New Jersey
Please note that employees in New Jersey may be eligible for wage replacement benefits under the state Temporary Disability and Family Leave Insurance law (TDI/FLI). Employers cannot use this application to administer any part of the TDI/FLI. Employers must post notice of this law. See the Reference Center for more detail.

New York
Nearly all (Employees who work 20 or more hours per week are eligible for leave after 26 weeks of employment.  Employees who work less than that are eligible for a prorated amount of leave after 175 days worked.) private employees in New York State are eligible for New York Paid Family Leave (PFL).  Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage (The number of weeks and amount of payment will increase every year until 2021, when eligible employees will be able to take up to 12 weeks of leave paid at 67% of their average weekly wage.}. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.  

New York State has developed a set of forms for employees and employers to use in order to administer PFL.  If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time.  If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app.  However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law (TDI). Employers cannot use this application to administer any part of TDI. Employers must post notice of this law. See the Reference Center for more detail.

Vermont
Under Vermont law, an employer cannot require medical certification for parental leave (including leave during the pregnancy and following the birth of the employee’s child)

Virginia
Please note that effective December 1, 2028 (employees and employers will begin making contributions on April 1, 2028) employees in Virginia may be eligible for paid leave under the state Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility (Employees needing medical leave for their own serious health condition, or family leave to care for a family member, to bond with a newborn or newly adopted child, or because of an military exigency can take up to 12 weeks of paid family and 12 weeks of medical leave,  for a combined total of 16 weeks of family and medical leave per claim year.   In addition, an employee can take two additional weeks of medical leave if the reason for leave is due to pregnancy complications.  An employer is required to provide an employee a Notice of Rights five business days after the employee's seventh consecutive day of absence due to family or medical leave, or within five business days after the employer has received notice that the employee's absence is due to family or medical leave, whichever is later.) and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers not be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Military Caregiver Leave

Overview

This form can be used to collect information about the medical condition for current service members and veterans.  It should be given to the employee, who will then provide it to the service member’s health care provider to fill in. The company can then use the information on the form to confirm that request leave qualifies under FMLA and related state leave laws, and that the employee’s caregiver leave is protected under the law.  Failure to provide sufficient certification can be grounds to deny a leave of absence.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company created a Notice of Eligibility form. Please note that best practice is to send any necessary certification forms along with the Notice of Eligibility.

back to top

Work State Information

Where does the Employee work? 

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

Connecticut
Leave is allowed under CTFMLA’s military leave provision only if the service member is a current member of the armed forces, or is on the “temporary disability retired list.”

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages.  The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption. The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

New York
The New York Paid Family Leave (PFL) law becomes effective, meaning that nearly all private employees in New York State will be eligible for Paid Family Leave.  Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.  

New York State has developed a set of forms for employees and employers to use in order to administer PFL.  If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time.  If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app.  However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers will no longer be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Military Emergency

Overview

This form can be used to collect information about the military exigency  It should be given to the employee, who will then provide it to the appropriate military personnel to fill in.  The employer can then use the information on the form to confirm that request leave qualifies under FMLA and related state leave laws, such that the employee’s leave is protected under the law.  Failure to provide sufficient certification can be grounds to deny a leave of absence.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company created a Notice of Eligibility form. Please note that best practice is to send any necessary certification forms along with the Notice of Eligibility.

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Work State Information

Where does the Employee work? 

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages.  The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption. The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

New York
The New York Paid Family Leave (PFL) law becomes effective, meaning that nearly all private employees in New York State will be eligible for Paid Family Leave. Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.

New York State has developed a set of forms for employees and employers to use in order to administer PFL. If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time. If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app. However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through thePaid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers will no longer be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Designation Notice

Overview

This notice either informs employees whether or not they are qualified for a protected leave, or instructs the employee as to what further information the employer needs in order to make a qualification decision.  An employer must inform the employee of its qualification decision within 5 business days of having enough information to make the determination.  This form is similar to the DOL’s Form WH-382, but also provides state-specific requirements and other relevant information.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company made an eligibility determination and completed a Notice of Eligibility form.  If you haven't sent the Notice of Eligibility form, you should send it together with the completed Designation Notice form.

  • If additional information was needed from the employee, you explained (via the Notice of Eligibility) what information was needed and sent any required certification forms along with the Notice of Eligibility. The employee is required to return the certifications and any additional information within 15 days of receiving the request.  If it is past the deadline and you have not received this information, consider sending the employee a reminder letter with a new deadline to return the information. 

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Work State Information

Where does the Employee work? 

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

California
Please note that employees in California may be eligible for wage replacement benefits under the State Disability Insurance law (Paid Family Leave). Employers cannot use this application to administer any part of the state disability insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

Delaware
Please note that employees in Delaware may be eligible for paid leave under the Healthy Delaware Families Act (Delaware Paid Leave). Employers cannot use this application to administer any part of Delaware Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible (Nearly all employees, no matter employer size, will be eligible for paid leave rights if they spend at least 50% of their time working in D.C.) employees state-provided wage replacement benefits based on the employee’s weekly wages. The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance (TDI) law. Employers cannot use this application to administer any part of the TDI.  Employers must post notice of this law. See the Reference Center for more detail.

Maine
Please note that employees in Maine may be eligible for paid leave under the Maine Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Maryland
Please note that effective January 2028 (employees and employers will begin making contributions on January 1, 2027) employees in Maryland may be eligible for paid leave under the Family and Medical Leave Insurance law (Maryland FAMLI). Employers cannot use this application to administer any part of Maryland FAMLI. Employers must post notice of this law. See the Reference Center for more detail.

Massachusetts
The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption (An employer can apply to the state for an exemption from collecting, remitting, and paying PFML contributions.  The employer’s plan must provide benefits greater than or equal to the benefits provided by the PFML law, as well as provide the same rights and protections.). The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

Minnesota
Please note that employees in Minnesota may be eligible for paid leave under the Minnesota Paid Leave law (Minnesota Paid Leave). Employers cannot use this application to administer any part of Minnesota Paid Leave. Employers must post notice of this law. See the Reference Center for more detail.

New Jersey
Please note that employees in New Jersey may be eligible for wage replacement benefits under the state Temporary Disability and Family Leave Insurance law (TDI/FLI). Employers cannot use this application to administer any part of the TDI/FLI. Employers must post notice of this law. See the Reference Center for more detail.

New York
Nearly all (Employees who work 20 or more hours per week are eligible for leave after 26 weeks of employment.  Employees who work less than that are eligible for a prorated amount of leave after 175 days worked.) private employees in New York State are eligible for New York Paid Family Leave (PFL).  Eligible employees needing leave for care of a family member, child bonding and military exigency can take up to 8 weeks of leave paid at 50% of their average weekly wage (The number of weeks and amount of payment will increase every year until 2021, when eligible employees will be able to take up to 12 weeks of leave paid at 67% of their average weekly wage.}. Please note that NY PFL differs from similar state laws because it not only grants protected time off, but it also provides payment during a leave.  

New York State has developed a set of forms for employees and employers to use in order to administer PFL.  If an employee is also eligible to take an FMLA leave, leave taken under PFL will run at the same time.  If an employee’s leave of absence runs under both FMLA and PFL, the employer can still administer FMLA leaves using the forms in this app.  However, in order to administer PFL, employers will also need to follow the PFL process mandated by New York; the process for requesting and certifying NY PFL is substantially different.

Please see New York’s website and your paid family leave insurer for access to PFL request and certification forms and more information.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law (TDI). Employers cannot use this application to administer any part of TDI. Employers must post notice of this law. See the Reference Center for more detail.

Virginia
Please note that effective December 1, 2028 (employees and employers will begin making contributions on April 1, 2028) employees in Virginia may be eligible for paid leave under the state Paid Family and Medical Leave law (PFML). Employers cannot use this application to administer any part of the PFML. Employers must post notice of this law. See the Reference Center for more detail.

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility (Employees needing medical leave for their own serious health condition, or family leave to care for a family member, to bond with a newborn or newly adopted child, or because of an military exigency can take up to 12 weeks of paid family and 12 weeks of medical leave,  for a combined total of 16 weeks of family and medical leave per claim year.   In addition, an employee can take two additional weeks of medical leave if the reason for leave is due to pregnancy complications.  An employer is required to provide an employee a Notice of Rights five business days after the employee's seventh consecutive day of absence due to family or medical leave, or within five business days after the employer has received notice that the employee's absence is due to family or medical leave, whichever is later.) and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD).

Since the state of Washington is now administering the wage replacement benefits and application forms, employers not be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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Return to Work

Overview

This is a form that can be used when the company needs a health care provider's certification prior to an employee's return to work.

  • Louisiana’s pregnancy disability leave law does not contain an affirmative provision allowing for certification, but does require the employee to provide reasonable notice.

  • Vermont does not have a provision regarding return to work certifications.  Under Vermont law, an employer cannot require medical certification for parental leave (including leave during the pregnancy and following the birth of the employee’s child.

When to create this form:

  • The company received notice that an employee needs a leave of absence from work.

  • The company made an eligibility determination and completed and sent a Notice of Eligibility form along with any applicable certification forms.

  • Employee returned any applicable forms or information needed to make a leave determination.
    The company created and sent a Designation Notice form approving the employee’s leave absence.

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Work State Information

Where does the Employee work?

The "work state" is the state in which the employee works and may be different from the state where the employee resides. If the employee works in more than one state, it is possible that the laws in all work states will apply.

Colorado
Colorado employees may be eligible for state wage replacement benefits through the Family and Medical Leave Insurance program (FAMLI), the state’s paid family leave program. Employers cannot use this application to administer any part of the FAMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA.

The FAMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for FAMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits.  The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, FAMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with other paid leave benefits.  Please see Colorado’s website and the Reference Center for more information about leave in Colorado.

District of Columbia
Employees in Washington D.C. may be eligible for leave under the Universal Paid Leave Act (UPLA).  Employers cannot use this application to administer any part of the UPLA.  The UPLA program is administered by the Office of Paid Family Leave, a division of D.C.’s Department of Employment Services.  Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under D.C.’s Family and Medical Leave Act.

The UPLA grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages.  The District will decide employee eligibility and administer wage replacement benefits.  The employer must post a notice about the UPLA and provide notice during hire, annually, and any time paid family leave may be needed.  Employers can determine whether their sponsored paid leave benefits run concurrently with their workers’ use of the District’s Paid Family Leave program. However, an eligible individual’s right to UPLA benefits will not be diminished by an employer’s paid leave policy.  The law provides no reinstatement rights at the end of the employee’s leave, but the employer must still comply with the FMLA and D.C.’s Family and Medical Leave Act to the extent there is any overlap.  Employees may also still be eligible for other types of paid leave under other applicable laws and the particular employer’s policy.  See The District’s website and the Reference Center for more detailed information about employee rights and employer responsibilities under the UPLA.

Hawaii
Please note that employees in Hawaii may be eligible for wage replacement benefits under the state Temporary Disability Insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Louisiana
PDL does not contain an affirmative provision allowing for certification, but does require the employee to provide reasonable notice.

Massachusetts
The Massachusetts Paid Family and Medical Leave Law (MA PFML) provides qualifying employees with state-mandated leave as well wage replacement benefits.  The leave and wage replacement benefits are administered by the state of Massachusetts, unless the employer is granted an exemption. The wage replacement benefit is based on the employee’s historical wages, the state’s average wage, and other factors. Nearly all employees, no matter employer size, as well as some former employees and independent contractors, will be eligible for the paid leave rights.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA. Employees who qualify for paid leave und MA PFML may also still be eligible for unpaid leave under the Massachusetts Parental Leave Law or FMLA; however leave under MA PFML will run concurrently with FMLA and Massachusetts Parental Leave Law. Since the state of Massachusetts is now administering the wage replacement benefits and application forms (unless employers are granted an exemption), employers will not be able to use this application to produce forms for purposes of administering Massachusetts Paid Family and Medical Leave. Employers can still administer leaves of absence under the FMLA or Massachusetts Parental Leave Law by using the forms in this app. Please see Massachusetts’ website and the Reference Center for more information about leave in Massachusetts, including MA PFML and Massachusetts Parental Leave Law.

Oregon
Oregon employees may be eligible for state wage replacement benefits through the Paid Leave Oregon (PFMLI) program, the state’s paid family leave program. Employers cannot use this application to administer any part of the PFMLI program benefits. Employers can still use the forms in this application to administer federal leaves of absence under the FMLA and leaves taken under Oregon’s Family Leave Act.

The PFMLI program grants time off and also provides eligible employees state-provided wage replacement benefits based on the employee’s weekly wages. Employees apply for PFMLI benefits through the state, and the state decides employee leave eligibility and administers wage replacement benefits. The employer must provide written notice to each employee of their duties and rights under the law. Depending on the specific leave request, PFMLI benefits may run concurrently with the employee’s use of leave under the FMLA or with any employer-sponsored paid leave benefits. Please see Oregon’s website and the Reference Center for more information about leave in Oregon.

Rhode Island
Please note that employees in Rhode Island may be eligible for wage replacement benefits under the state Temporary Disability Insurance law. Employers must post notice of this law. See the Reference Center for more detail.

Vermont
Vermont does not have a provision regarding return to work certifications. Under Vermont law, an employer cannot require medical certification for parental leave (including leave during the pregnancy and following the birth of the employee’s child).

Washington
Washington’s Family and Medical Leave Act was repealed and replaced by Washington’s Paid Family and Medical Leave Act (WA PFML), and wage replacement benefits are now administered by the state of Washington.  WA PFML not only grants time off, but it also provides that the eligible employee will receive a state-provided wage replacement benefit based on the employee’s historical wages, the state’s average wage, and other factors.  Nearly all employees, no matter employer size, will be eligible for the paid leave rights after having worked 820 hours (about 16 hours a week) for any employer (not just their current employer) in a qualifying period.  Washington will decide employee eligibility and administer wage replacement benefits.  At the end of the leave, the employer must abide by the reinstatement rights imposed by the law, which are triggered under circumstances similar to the FMLA, although, even if the employee does not meet the requirements for job reinstatement rights, there may be other bases for job-protection during the WA PFML leave.  Employees seeking pregnancy disability leave may also still be eligible for unpaid leave under the Washington Law Against Discrimination (WLAD). 

Since the state of Washington is now administering the wage replacement benefits and application forms, employers will no longer be able to use this application to produce forms based on Washington state law.  Employers can still administer federal leaves of absence under the FMLA by using the forms in this app.  Please see Washington’s website and the Reference Center for more information about leave in Washington, including WA PFML and WLAD.

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