Fillable FMLA HRIS ENTRY FORM ARIZONA STATE PERSONNEL SYSTEM (Arizona)

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FMLA HRIS ENTRY FORM ARIZONA STATE PERSONNEL SYSTEM (Arizona)

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ADOA Shared Services – February 2013
ARIZONA STATE PERSONNEL SYSTEM
FMLA HRIS ENTRY FORM
Select one: Initial Set-up Change Leave Record # _____
EMPLOYEE INFORMATION
Employee’s Full Name (Last, First, MI)
EIN
Alternate Mailing Address
(if different from home address)
FMLA DATES
FMLA Start Date
FMLA End Date
Employee FMLA Request Date
Employee Return to Work Date
REASON FOR FMLA
TYPE OF FMLA LEAVE
FMLA LEAVE STATUS
Did the employee use any FMLA hours in ETE while they were in pending status?
YES NO
NOTIFICATION DATES
Request for FMLA received on
Physician Certification received on
DOCUMENT DATES
Notification of Rights – Date Sent
Date Manager Notified of FMLA Request / Determination
AGENCY CONTACT INFORMATION
Agency Name
Agency FMLA Coordinator
FMLA Coordinator Phone
FMLA Coordinator Email
Email completed form to humanresources@azdoa.gov
THIS FORM IS FOR HRIS DATA ENTRY ONLY
It is the Agency’s responsibility to verify that the employee is eligible for FMLA, track the
employee’s FMLA time and report any changes that would affect HRIS accessibility/entry.
Choose FMLA Leave Type
Choose FMLA Leave Status
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FMLA HRIS ENTRY FORM ARIZONA STATE PERSONNEL SYSTEM (Arizona)

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Completed 12 August 2020

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