FMLA Leave Request Form Template

FMLA Leave Request Form

Date of Request: [Date]

1. Employee Information

Employee Name: [Full Name]
Employee ID Number, if applicable: [Number]
Job Title: [Job Title]
Department: [Department]
Work Location: [Location]
Phone Number: [Phone Number]
Email Address: [Email Address]

Supervisor Name: [Supervisor Name]
Supervisor Email or Contact Information: [Contact Information]

2. Leave Request Information

I am requesting leave that may qualify under the Family and Medical Leave Act.

Requested leave start date: [Date]
Requested leave end date: [Date]

Estimated total time requested:

[Number of days / weeks / hours]

3. Type of Leave Requested

Requested leave format:

☐ continuous leave
☐ intermittent leave
☐ reduced work schedule
☐ unknown at this time

If intermittent or reduced schedule leave is requested, describe the expected schedule:

[Insert details]

4. Reason for Leave Request

The leave request relates to the following:

☐ my own serious health condition
☐ care for a spouse with a serious health condition
☐ care for a child with a serious health condition
☐ care for a parent with a serious health condition
☐ birth of a child and bonding
☐ placement of a child for adoption or foster care
☐ qualifying military exigency
☐ care for a covered servicemember
☐ other: [Describe]

General description of the reason for leave:

[Insert description]

5. Family Member Information, if Applicable

If this request relates to care for a family member, complete the following:

Family Member Name: [Full Name]
Relationship to Employee: [Relationship]

Additional details, if needed:

[Insert details]

6. Foreseeable or Unforeseeable Leave

This leave is:

☐ foreseeable
☐ unforeseeable
☐ partially foreseeable
☐ emergency-related

If foreseeable, explain when I first became aware of the need for leave:

[Insert details]

If unforeseeable, explain briefly:

[Insert details]

7. Medical Treatment or Scheduling Information

If applicable, I expect the leave to involve:

☐ inpatient care
☐ outpatient treatment
☐ scheduled appointments
☐ recovery period
☐ ongoing treatment
☐ unknown at this time

Known appointment or treatment schedule, if applicable:

[Insert dates and details]

8. Certification Information

A medical or military certification:

☐ is attached
☐ will be provided
☐ has been requested from the provider
☐ may not be required
☐ unknown at this time

Expected certification submission date, if known:

[Date]

9. Paid Leave and Time-Off Information

I understand that this request may involve unpaid leave unless paid leave is available or required to run concurrently.

Available leave I may use or request concurrently:

☐ vacation
☐ sick leave
☐ PTO
☐ personal leave
☐ other: [Describe]
☐ unknown at this time

10. Contact During Leave

Preferred contact method during leave:

☐ phone
☐ email
☐ mail
☐ other: [Describe]

Best contact information during leave:

[Insert details]

11. Return-to-Work Information

Expected return-to-work date, if known:

[Date]

If unknown, explain:

[Insert details]

Work restrictions or accommodation concerns, if known:

[Insert details]

12. Employee Statement

I am requesting leave that I believe may qualify for FMLA protection. I understand that additional information or certification may be required and that I must follow my employer’s usual notice procedures unless I am unable to do so.

Employee Signature: __________________________
Name: [Full Name]
Date: [Date]

13. Employer / HR Use Only

Date received: [Date]
Received by: [Name / Title]

Initial review notes:

[Insert details]

Eligibility notice provided:

☐ yes
☐ no
Date: [Date]

Rights and responsibilities notice provided:

☐ yes
☐ no
Date: [Date]

Certification requested:

☐ yes
☐ no
Date: [Date]

Designation decision:

☐ pending
☐ approved
☐ denied
☐ additional information needed

Additional HR notes:

[Insert details]