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Run: Concurrent Leave Tracking Worksheet

Track one absence across FMLA, ADA, PWFA, state PFML, and workers' comp in a single worksheet. Use it to coordinate overlapping entitlements, document decisi...

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Case Overview

Case reference

System-generated reference for the leave case.

Employee name (required)

Enter the employee's name for case tracking.

Employee ID

Optional internal identifier if used by your organization.

Department (required)

Department or work unit associated with the leave case.

Primary case type (required)

Submission date (required)

Date this worksheet is completed.

Case owner (required)

HR, leave administrator, or case manager responsible for the file.

Absence Details

Absence start date (required)

First date of the absence or reduced schedule.

Absence end date

Leave blank if the absence is ongoing.

Current absence status (required)

Reason category (required)

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? (required)

Does ADA apply? (required)

Does PWFA apply? (required)

Does state PFML apply? (required)

Does workers' compensation apply? (required)

Other applicable programs

Eligibility and Certification

FMLA eligibility status

FMLA certification status

Is medical support needed for ADA review?

PWFA accommodation requested

Yes No N/A

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? (required)

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? (required)

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 (required)

Yes No N/A

Consent to contact employee for leave administration (required)

Anonymous submission requested

Use only if your process allows anonymous intake for concerns or escalations; leave unchecked for standard case management.

Yes No N/A

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.

Get your results

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