:
Employee FMLA Leave Request
(Family/Medical Leave Request Form)
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to 12 or 26 weeks of job-protected
leave for certain family and medical reasons. Submit this request form to your human resources manager at least 30 days before the
leave is to begin, when possible. When 30 days’ advance submission of the request form is not possible, submit the request as soon as
possible. Our Company reserves the right to deny or postpone leave if you do not give adequate notice when permitted under federal and/or
state law.
Employee Information
Please print.
Name:
Reason for Requesting Leave
I am requesting family/medical leave for the following reasons: (check all that apply)
Employee ID #:
Department: Job Title:
Today’s Date
Hire Date:
Supervisor:
Status: ☐Full-Time ☐Part-Time ☐Temporary
☐Birth of my child; to care for my newborn
child
☐Placement of a child with me for ☐ adoption ☐ foster care
☐Leave to car
e for a family member with a serious health condition
Relationship of family m ember to you:
☐My own serious health condition
☐Qualifying exigency because a family member is on or has been called to covered active duty in the Regular Armed Forces (including
the National Guard and Reserves) to a foreign country
Relationship of family m ember to you:
☐Leave to care for a family member who is a current member of the Armed Forces (including the National Guard and Reserves) or a
covered veteran and who is undergoing medical treatment, recuperation, or therapy, is in outpatient status or on temporary disability
retired list for a serious injury or illness
Relationship of family m ember to you:
☐Other (please explain)
Duration of Leave
Leave expected to begin: Leave expected to end:
If intermittent or reduced-leave schedule is bei
ng requested, please explain why it is needed and the proposed leave schedule:
Employee Certification and Signature
I certify that the above information is true and correct to the best of my knowledge:
Employee signature:
Date
:
EMPLOYER: This form s
hould be treated as a medical record and must be maintained separately from employee personnel files,
in locked
cabinets with only designated personnel having access. As an employer, you should retain this original and provide a photocopy of the form
to your employee along with the Company Response form within a reasonable period of time.
This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal
opinions on any specific facts or services. The information is provided with the
understanding that any person or entity involved in creating, producing
or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your
particular situation and any specific questions or concerns you may have.
click to sign
signature
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