Concurrent Leave Tracking Worksheet

Worksheet for tracking a single absence across overlapping leave and accommodation entitlements, including FMLA, ADA, PWFA, state PFML, and workers' compensation.

Case Overview

• Case reference
  System-generated reference for the leave case.
• Employee name
  Enter the employee's name for case tracking.
• Employee ID
  Optional internal identifier if used by your organization.
• Department
  Department or work unit associated with the leave case.
• Primary case type
• Submission date
  Date this worksheet is completed.
• Case owner
  HR, leave administrator, or case manager responsible for the file.

Absence Details

• Absence start date
  First date of the absence or reduced schedule.
• Absence end date
  Leave blank if the absence is ongoing.
• Current absence status
• Reason category
  Use a broad category to support progressive disclosure and data minimization.
• Intermittent leave frequency
  If intermittent leave applies, describe the expected pattern in plain language.
• Reduced schedule details
  Describe the approved reduced schedule, if applicable.

Applicable Programs

• Does FMLA apply?
• Does ADA apply?
• Does PWFA apply?
• Does state PFML apply?
• Does workers' compensation apply?
• Other applicable programs

Eligibility and Certification

• FMLA eligibility status
• FMLA certification status
• Is medical support needed for ADA review?
• PWFA accommodation requested
• State PFML certification status
• Workers' compensation claim number
  Enter the claim number if one has been assigned.

Concurrent Leave Coordination

• Will the leave run concurrently where permitted?
• Programs running concurrently
• Paid leave coordination
  Describe how paid leave, wage replacement, or offsets are being coordinated.
• Benefits impact notes
  Summarize any benefits continuation, premium payment, or eligibility impacts.
• Schedule impact
  Note any shift, staffing, or return-to-work scheduling considerations.

Accommodation and Return to Work

• Was a reasonable accommodation requested?
• Accommodation type
• Return-to-work restrictions
  List any restrictions, limitations, or work status notes relevant to return to work.
• Interactive process status

Notes, Consent, and Audit Trail

• PII notice acknowledged
• Consent to contact employee for leave administration
• Anonymous submission requested
  Use only if your process allows anonymous intake for concerns or escalations; leave unchecked for standard case management.
• Decision summary
  Summarize the concurrent leave determination, including any partial overlaps or pending items.
• Follow-up actions
  Track next steps, documentation requests, and follow-up deadlines.