The Essential Guide to Family & Medical Leave

appendix C | forms and checklists | 363
FMLA Hours Worked
Fill out this worksheet for each employee who requests leave, to verify that the employee
is eligible under the FMLA. Don’t put more than one name on the worksheet—the
information should go in each employee’s confidential file. If an employee requests
multiple leaves in the same year, simply add rows to the worksheet.
Employee Name
Start Date
Hours Worked in
the 12 Months Prior
to Requested Leave
Dates FMLA
Leave Taken