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Family and Medical Leave Act (FMLA) Forms

(Updated 04/30/09) These forms provide supporting documentation for leave requests covered by the Family and Medical Leave Act (FMLA). These forms have been updated to meet the requirements of the revised regulations that became effective Jan. 16, 2009. More information about the new requirements is available here.

Although employees are entitled to submit their medical certification in any format, the APWU has created its own APWU FMLA forms for our members to use. Please note that regardless of what format is used for the medical certification, the Health Care Provider must provide the information required under the FMLA in order for the certification to be considered complete and sufficient. If a medical certification is not sufficiently completed by the Health Care Provider, instead of denying the leave, the Postal Service is required to explain to the employee in writing what additional information is necessary to make the certification complete and sufficient, and give the employee an opportunity to submit the additional required information. The employee may, for example, have their Health Care Provider write the additional required information on their original certification, or have the Health Care Provider attach a note containing the additional required information.

Please note that some of these forms have been modified slightly for clarity since they were initially issued in February 2009. APWU FMLA forms #1 and #2 were revised as follows: 1) a change to the section regarding medical facts to include treatment, if any; 2) a clarification regarding what constitutes a chronic condition (i.e. the new regulations stipulate that to qualify as a chronic condition, the employee must require treatment at least twice a year, and 3) a place for the HCP to print their name, above where they place their signature. This last change also applies to form #4. Form #3 is unchanged. While the February 2009 version of the forms should still be acceptable when properly completed, these revisions add clarity and should, therefore, reduce the number of instances where the Postal Service finds the forms “insufficient” or “incomplete.”

APWU FMLA Form #1 [pdf]

Certification by Employee's Health Care Provider for Employee's Own Serious Illness

APWU FMLA Form #2 [pdf]

Health Care Provider Certification of Employee's Family Member Serious Illness

APWU FMLA Form #3 [pdf]

Certification by Employee of Qualifying Exigency for Military Family Leave

APWU FMLA Form #4 [pdf]

Certification by Service Member's Health Care Provider for Caregiver Military Family Leave

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