FMLA Leave Tracking Chart

Chart to keep track of how much money you will receive if you leave work for health reasons DONE

Summary

What happens when you take time off may be more clear if you chart it. Survivorship A to Z provides a chart that includes:

The twelve weeks an employee is entitled to under the Family and Medical Leave Act (FMLA)
Your income, and where it will come from.

You can see a sample to give you an idea how to complete the chart in the next section. The last section of this article is the chart.

If you intend to be out of work for a longer period of time, make additional copies of the chart. Use one chart for each calendar quarter.

Following is a sample for Anna Doe to show you how to use the chart.

Anna was entitled to Sick Leave, Short Term Disability Insurance, Vacation and time off under the FMLA
Note that Anna took only a little more than two months off. She was lucky enough to have Short Term Disability to pick up when the Sick Leave ran out. If you are not so lucky, you may have no income for several weeks.

Sample Leave Tracking Chart for Jane Doe

Week Ending	Week	Income	Source of Income	Benefits Continued?
03-21-07*	1	Full	Sick Leave	Yes
03-28-07	2	Full	Sick Leave	Yes
04-04-07	3	3 days full 4 days @ 60%	Sick Leave Short Term Disability	Yes
04-11-07	4	60%	Short Term Disability	Yes
04-18-07	5	60%	Short Term Disability	Yes
04-25-07	6	60%	Short Term Disability	Yes
05-02-07	7	60%	Short Term Disability	Yes
05-09-07	8	60%	Short Term Disability	Yes
05-16-07	9	60%	Short Term Disability	Yes
05-23-07	10	Full	Back to Work**	Yes
05-30-07	11	Full	Back to Work**	Yes
06-06-07	12	Full	Back to Work**	Yes
This chart assumes the last day Jane worked was 03-13-07 *Anna has three more weeks of FMLA available to use before 03-14-08 (twelve months from her first day of FMLA leave).