FMLA Forms

LARIMER COUNTY FORMS

Use these forms to complete request for Family Medical Leave (FMLA)

• Family and Medical Leave Request Form (LCHR-49) - Online
• Family and Medical Leave Request Form (LCHR-49) - PDF
• Application for Donated Sick Leave (LCHR-125)
• Medical Leave of Absence Request Form (LCHR-60)

DEPARTMENT OF LABOR INFORMATION

• WH-380-E Certification of Health Care Provider for Employee's Serious Health Condition
• WH-380-F Certification of Health Care Provider for Family Member's Serious Health Condition
• WH-381 Notice of Eligibility and Rights & Responsibilities
• WH-384 Certification of Qualifying Military Exigency for Military Family Leave
• WH-385 Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave
• WH-385-V Certification for Serious Injury or Illness of Veteran for Military Caregiver Leave