FMLA Eligibility Checklist

1. Employer Requirements

Check all that apply to the employer:

Total Employees within 75 miles: Requires 50 or more.

2. Employee Requirements

Time Employed (Months) Requires 12 months (or 52 weeks).

Hours Worked in Last 12 Months Requires 1,250 hours.

3. Reason for Leave

Qualifying Reason

FMLA Eligibility Determination

Based on criteria established by the Department of Labor (DOL)

ELIGIBILITY STATUS: NOT ELIGIBLE

Summary of Eligibility Criteria

Criteria	Requirement Met?	Data Point

Conclusion and Next Steps

The employer meets the minimum requirements, but the employee does not meet the hours worked requirement. The employee is currently not eligible for FMLA leave.

*Disclaimer: This tool provides a preliminary check only and is not legal advice. Consult official FMLA documentation or legal counsel for final determination.