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Run: Leave Exhaustion Analysis Worksheet

Track an employee’s leave as FMLA entitlement nears exhaustion, document the calculation, and record next steps for ADA review and return-to-work planning.

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Case Overview

Employee Name (required)

Employee ID

Optional if your organization uses a separate case identifier. Avoid collecting unnecessary PII.

Department

Leave Case Number (required)

Review Date (required)

Current Leave Status

Leave Type (required)

Leave Start Date (required)

Current Leave Status (required)

Entitlement Period (required)

Total Entitlement (Hours) (required)

Enter the total protected leave entitlement available under the applicable policy or law.

Used Entitlement (Hours) (required)

Enter the amount already used as of the review date.

Remaining Entitlement (Hours)

Exhaustion Analysis

Is leave nearing exhaustion? (required)

Projected Exhaustion Date

Analysis Basis (required)

Estimated Remaining Timeframe

Analysis Notes

Summarize how remaining entitlement was calculated and any assumptions used.

Next Steps and ADA Review

Primary Next Step (required)

Is an ADA reasonable-accommodation review needed? (required)

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? (required)

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.

Yes No N/A

Reviewer Name (required)

Reviewer Title

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