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FMLA Leave Tracking Chart
A Sample Leave Tracking Chart
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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). |
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