Family Medical Leave Act Document

A family medical leave act document is an important record of the conditions that has led to the granting of temporary leave for certain medical circumstances concerning one’s own self or his/ her family. This act for leave is justified under the U.S federal law that places upon employers the responsibility to provide job-protected and unpaid leave to employees for reasonable purposes regarding family as well as personal health issues, such as, illness, family sickness, child foster care placement, adoption, pregnancy, etc.

You can Download the Free Family Medical Leave Act Document customize it according to your needs and Print. Family Medical Leave Act Document is either in MS Word, Excel or in PDF.

Sample Family Medical Leave Act Document:

Family Medical Leave Act Document

Download Free Family Medical Leave Act Document

Document prepared for: Mr. Mike Jacobson

Age: 35 years

Employee at: George Group of Companies

New York

Designation: Finance Head


The reason for this particular family medical leave act document is that Mike’s daughter, Angela Jacobson, aged 15, has suddenly fallen ill with an acute breathing problem. She had to be hospitalized on the 16th day of December, 2011 at the St. Patrick City Nursing Home. Hence, Mr. Mike Jacobson has been granted a medical leave under the Family Medical Leave Act for a term of 10 days, which may be considered for extension in case her daughter’s condition does not completely improve by then.

Benefits under the Family Medical Leave Act:

  • Health insurance facilities and premiums from the employer will be granted as part of the Act.
  • Mr. Mike Jacobson will be restored to his services, at the same position, once he returns from the family medical leave. The pay of the employee, job benefits, and work responsibilities will remain unchanged in form and standards.
  • The employee will be provided with the same rights and employee securities.
  • Mike will be protected from any sort of job distinction or biasness, if done, by the employer.

Posted in Medical Documents