Wondering if you qualify for FMLA or short-term disability?

Answer a few quick questions to see your likelihood of eligibility. This takes about 2 minutes — a licensed provider will confirm your actual eligibility at your evaluation.

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First Name *

Phone *

Email *

Q1. How long have you worked for your current employer? *

Less than 12 months

12 months or more

Q2. In the past 12 months, have you worked at least 1,250 hours for this employer (roughly 24+ hours/week on average)? *

Yes

Not sure

Q3. Does your employer have 50 or more employees within 75 miles of your worksite? (This also applies automatically if you work for a public agency or a public/private school.) *

Yes

Not sure

I work for a school or government agency

Q4. What's the main reason you're considering leave? *

My own health condition

Pregnancy or recent childbirth

Bonding with a new child (birth, adoption, or foster placement)

Caring for a family member's serious health condition

Military family exigency or caring for an injured/ill servicemember

None of these / not sure

Q5a. In the past 12 months, has this condition involved any of the following? (select all that apply) *

An overnight hospital, hospice, or residential medical care stay

Treatment by a provider at least twice a year for an ongoing/chronic condition (e.g. asthma, diabetes, migraines)

Being unable to work for more than 3 consecutive days, with medical treatment

Ongoing supervision by a provider for a permanent or long-term condition

Multiple treatments for a condition that would otherwise cause repeated absences (e.g. chemotherapy, dialysis, physical therapy after surgery)

None of the above

Q5b. Are you currently pregnant, or did you give birth within the last 12 months? *

Yes

Q5c. Was the birth, adoption, or foster placement within the last 12 months? *

Yes

Q5d-1. What is your relationship to this family member? *

Spouse

Child

Parent

Other (parent-in-law, sibling, domestic partner, etc.)

Q5d-2. In the past 12 months, has their condition involved any of the following? (select all that apply) *

An overnight hospital, hospice, or residential medical care stay

Treatment by a provider at least twice a year for an ongoing/chronic condition (e.g. asthma, diabetes, migraines)

Being unable to work for more than 3 consecutive days, with medical treatment

Ongoing supervision by a provider for their permanent or long-term condition

Multiple treatments for a condition that would otherwise cause repeated absences (e.g. chemotherapy, dialysis, physical therapy after surgery)

None of the above

Q5e. Is this related to: *

A family member's military deployment (exigency leave)

Caring for a covered servicemember's serious injury or illness (caregiver leave, up to 26 weeks)

Not sure

Q6. What state do you currently work in? *

Outside Our Service Area

Thanks for your interest - at this time, Precision Medical Docs only provides evaluations in Arizona, Colorado, Florida, Iowa, Illinois, Kansas, Kentucky, Montana, Nevada, Oregon, Virginia, Washington, and Wyoming. We're not able to complete FMLA or disability documentation for patients outside these states.

Q7. Are you currently enrolled in a short-term disability (STD) program through your employer? *

Yes

Not sure