Employee FMLA Eligibility Determination Request Form

This form is intended for use by Henrico County General Government Employees, not School Employees. 
HCPS forms can be found on the “Locker” and on the Henrico County Public Schools website (under Important Links).

Employees: Submit this FMLA Eligibility Determination Request Form to the Department of Human Resources, Benefits Division, at least 30 days before the leave is to begin, when possible. When 30 days’ advance submission of this form is not possible, submit the request as soon as possible. A late submission of this form may delay your FMLA leave approval.

Supervisors: If the employee is unable to complete the form or needs assistance, it is the supervisor’s responsibility to do so. Note: This form is only used by Human Resources to determine whether an employee is eligible for FMLA leave and to notify them of their rights and responsibilities under FMLA. Immediate supervisors will be copied on the eligibility notice provided to employees.

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