"Fmla Return to Work Form"

What Is an FMLA Return to Work Form?

An FMLA Return to Work Form is a notification completed by the employee and submitted to their employer after an FMLA leave - a leave requested and provided under the provisions of the Family and Medical Leave Act - is over. Once you are back from your leave, the employer is under the obligation to give you the same job you held before the leave or, in certain circumstances, offer you an equivalent position with the same level of skills required, responsibilities, wage, benefits, perks, and location.

Alternate Name:

  • FMLA Return to Work Letter.

You can download a fillable FMLA Return to Work template below or draft a more personalized document using our online form builder. Here are some tips on how to create a proper FMLA Return to Work Letter:

  1. Indicate your name, position, and department. Add your social security number and contact details. Write down the name and telephone number or email address of your direct supervisor.
  2. Acknowledge your readiness to come back to work from the leave.
  3. If your leave was due to medical reasons, you may need a certification from your health care provider - your physician needs to confirm you are ready to go back to work by verifying your fitness and the release date. You may obtain a signature for your Return to Work form or ask your doctor to complete a separate statement - it is possible to file a medical certification within two weeks after the employer asks for it.
  4. Sign and date the document. Mail or present this letter to the human resources department and your direct supervisor.
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What Happens If My Employer Refuses an FMLA Return to Work Form?

FMLA Return to Work guidelines indicate several circumstances under which the employer reserves the right to deny your request to return. You might not be reinstated if:

  1. Your position was eliminated and you would not have your job back even without the leave - for instance, your division no longer exists and you would have been laid off.
  2. You can no longer perform functions considered essential for your job even with reasonable accommodation. The employee does not have to accept another position - you may decline it and prolong the leave until the employer offers you the same or equivalent job.
  3. You requested leave without a valid reason.
  4. Your reinstatement would bring severe economic loss to the business. This applies to so-called key employees - individuals who belong to the highest-paid 10% of the employees.

Additionally, if you sent the FMLA Return to Work Letter too late, for instance, a day before the date of return, the employer may not be prepared to welcome you back for various reasons. Traditionally, the employee needs to give the employer several business days to accept the notification and get in touch with them. The best course of action, however, is to come back on the day stated in the FMLA Request Form - the document you filled out to request leave in the first place.


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FMLA Return to Work Form
1. Employee Information.
Employee Name:
Employee ID:
Deptartment:
Work Phone:
Home Phone:
Employee’s Home
Address:
Email:
2. Medical Return to Work Certification (to be completed by the Health Care
Provider).
Name of Health Care
Provider:
Name of Health Care
Practice:
Address of Health
Care Practice:
Phone:
Date of Examination:
Name of Employee:
Name of Patient:
When is the employee released to return to work?
_____________________________________________________________________
Is the employee able to perform the essential functions of their position as of the
return to work date?
_____________________________________________________________________
Additional comments:​
_ __________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I, the Health Care Provider, affirm that the information provided above is true and
accurate to the best of my knowledge.
_______________________________
_______________________________
Health Care Provider’s Signature
Date
©​ ​ ​ ​
T EMPLATEROLLER.COM​
FMLA Return to Work Form
1. Employee Information.
Employee Name:
Employee ID:
Deptartment:
Work Phone:
Home Phone:
Employee’s Home
Address:
Email:
2. Medical Return to Work Certification (to be completed by the Health Care
Provider).
Name of Health Care
Provider:
Name of Health Care
Practice:
Address of Health
Care Practice:
Phone:
Date of Examination:
Name of Employee:
Name of Patient:
When is the employee released to return to work?
_____________________________________________________________________
Is the employee able to perform the essential functions of their position as of the
return to work date?
_____________________________________________________________________
Additional comments:​
_ __________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I, the Health Care Provider, affirm that the information provided above is true and
accurate to the best of my knowledge.
_______________________________
_______________________________
Health Care Provider’s Signature
Date
©​ ​ ​ ​
T EMPLATEROLLER.COM​
3. Certification of Return to Work (to be completed by the HR Representative).
Date leave of absence began: _____________________________________________
Date employee returned to work at regularly scheduled hours: ___________________
Employee​ is not​ returning to work. Separation Date is:​
_ ________________________
_______________________________
_______________________________
HR Representative’s Signature
Date
©​ ​ ​ ​
T EMPLATEROLLER.COM​
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