"Fmla Request Form"

What Is an FMLA Request Form?

An FMLA Request Form is a document completed by employees who are eligible for time off in compliance with the Family and Medical Leave Act provisions. Prepare this form when you discover the necessity of your absence, especially if it takes more than a couple of days off. This will allow your employer or human resources department to reschedule other employees' hours, keep everyone informed of their work schedule, organize proper pay for every employee in accordance with their hours, and avoid unnecessary strain on the employees and the business as a whole.

Alternate Names:

  • FMLA Leave Request;
  • FMLA Request Letter.

You can fill out an FMLA Leave Request Form in the following circumstances:

  1. Illness or injury that temporarily prevents you from going to work.
  2. Pregnancy disability.
  3. Care for a newborn or adopted child.
  4. Care for relatives (children, spouse, parents) who have serious health conditions.
  5. Care for minor children if you need to stay home with them as their place of care or school is closed.

You can download an FMLA Request Form template below.

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How to Request FMLA Leave?

FMLA Leave Request instructions are as follows:

  1. Indicate the title of the document - an FMLA Leave Request - at the top of the page;
  2. Write down your name, job title, department, mailing address, telephone number, and email address;
  3. State the start and end dates of the leave you want to request;
  4. Record the reason for submitting the request;
  5. Describe what kind of change in your employment you require - you may need a leave for a continuous period of time (several days, weeks, or months) or you may prefer to simply reduce your work schedule - a better choice for people who deal with medical conditions and have to arrange multiple appointments with their medical providers;
  6. Sign and date the form. Once it is completed, give it to the human resources department. Prepare a copy for your direct supervisor to make sure everybody understands the situation and you will not undermine the productivity and workflow of the organization by your sudden leave.

In addition to your request, you may be asked to file a certification completed and signed by your doctor. This document will contain a description of your condition or confirmation of your pregnancy. It verifies that you are not capable to work because of the reason indicated in the certification and records the duration of the leave. In case you fail to obtain a certification from your physician, the leave request may be delayed or even denied.

When you are prepared to return to work, you will need to fill out and submit the FMLA Return to Work Form - a document that notifies the employer of your intent to come back to work and contains your physician's confirmation that you are able to safely continue your active employment.


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FMLA Request Form
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to
________ weeks of job-protected leave for certain family and medical reasons. Submit this request
form to a human resources manager at least ________ days before the leave is to begin, when
possible.
The employer reserves the right to deny or postpone leave if the employee does not give adequate
notice when permitted under federal and/or state law.
1. Employee Information.
_______________________________
_______________________________
Name
Department
_______________________________
_______________________________
Employee ID
Job Title
_______________________________
_______________________________
Today’s Date
Hire Date
Supervisor ____________________________________________________________
Status ________________________________________________________________
2. Reason for Requesting Leave.
The employee is requesting family/medical leave for the following reasons:
❏ Birth of a child;
the Regular Armed Forces to a
foreign country;
❏ To care for a newborn child;
❏ Leave to care for a family
❏ To care for an adopted child;
member
who
is
a
current
member of the Armed Forces or
❏ Leave to care for a family
a covered veteran and who is
member with a serious health
undergoing medical treatment,
condition;
recuperation, or therapy;
❏ The employee’s own serious
❏ Other: ____________________
health condition;
__________________________
❏ Qualifying exigency because a
__________________________
family member is on or has been
called to covered active duty in
__________________________
©​ ​ ​ ​
T EMPLATEROLLER.COM​
FMLA Request Form
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to
________ weeks of job-protected leave for certain family and medical reasons. Submit this request
form to a human resources manager at least ________ days before the leave is to begin, when
possible.
The employer reserves the right to deny or postpone leave if the employee does not give adequate
notice when permitted under federal and/or state law.
1. Employee Information.
_______________________________
_______________________________
Name
Department
_______________________________
_______________________________
Employee ID
Job Title
_______________________________
_______________________________
Today’s Date
Hire Date
Supervisor ____________________________________________________________
Status ________________________________________________________________
2. Reason for Requesting Leave.
The employee is requesting family/medical leave for the following reasons:
❏ Birth of a child;
the Regular Armed Forces to a
foreign country;
❏ To care for a newborn child;
❏ Leave to care for a family
❏ To care for an adopted child;
member
who
is
a
current
member of the Armed Forces or
❏ Leave to care for a family
a covered veteran and who is
member with a serious health
undergoing medical treatment,
condition;
recuperation, or therapy;
❏ The employee’s own serious
❏ Other: ____________________
health condition;
__________________________
❏ Qualifying exigency because a
__________________________
family member is on or has been
called to covered active duty in
__________________________
©​ ​ ​ ​
T EMPLATEROLLER.COM​
3. Duration of Leave.
_______________________________
_______________________________
Leave expected to begin
Leave expected to end
If an intermittent or reduced-leave schedule is being requested, please explain why it
is needed and the proposed leave schedule:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4. Employee Certification and Signature.
The employee certifies that the above information is true and correct to the best of my
knowledge: Date:
_______________________________
_______________________________
Employee Signature
Date
This form should be treated as a medical record and must be maintained separately from employee
personnel files, in locked cabinets with only designated personnel having access.
©​ ​ ​ ​
T EMPLATEROLLER.COM​
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