Leave Exhaustion Analysis Worksheet

Worksheet to analyze remaining leave entitlement as FMLA leave nears exhaustion and document next steps, including ADA accommodation review and return-to-work planning.

Case Overview

• Employee Name
• Employee ID
  Optional if your organization uses a separate case identifier. Avoid collecting unnecessary PII.
• Department
• Leave Case Number
• Review Date

Current Leave Status

• Leave Type
• Leave Start Date
• Current Leave Status
• Entitlement Period
• Total Entitlement (Hours)
  Enter the total protected leave entitlement available under the applicable policy or law.
• Used Entitlement (Hours)
  Enter the amount already used as of the review date.
• Remaining Entitlement (Hours)

Exhaustion Analysis

• Is leave nearing exhaustion?
• Projected Exhaustion Date
• Analysis Basis
• Estimated Remaining Timeframe
• Analysis Notes
  Summarize how remaining entitlement was calculated and any assumptions used.

Next Steps and ADA Review

• Primary Next Step
• Is an ADA reasonable-accommodation review needed?
• ADA Review Reason
• Potential Accommodation Types to Review
• Next Steps Notes
  Document notices to be sent, deadlines, referrals, or other follow-up actions.

Employee Communication and Attestation

• Employee Notified of Review Outcome?
• Notification Method
• Consent to Contact Healthcare Provider if Needed
  Only collect this if your process requires employee authorization to seek clarification. Collect the minimum necessary information.
• Reviewer Name
• Reviewer Title