FMLA Leave Request Form Template: Employee Notice and Leave Details

Typical length: 4-6 pages
AI Assisted
Export: PDF & DOCX
Multi-jurisdiction ready

Get your custom agreement in minutes Create Agreement

4.8 Rating Downloaded 3612 times

Google For Startups NVIDIA Inception Program

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:

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:

If unforeseeable, explain briefly:

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:

11. Return-to-Work Information

Expected return-to-work date, if known:

If unknown, explain:

Work restrictions or accommodation concerns, if known:

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:

Eligibility notice provided:

☐ yes

☐ no

Date: [Date]

Rights and responsibilities notice provided:

Certification requested:

Designation decision:

☐ pending

☐ approved

☐ denied

☐ additional information needed

Additional HR notes:

Download Free Template

Get your complete
agreement in minutes

Select a template

Each template already follows legal structure and best practices.

Provide details

The agreement is automatically filled and adapted to your inputs.

Review & download

Check the generated document, make edits if needed, and download a ready-to-use agreement.

Details

Learn more about

FMLA Leave Request Form Template: Employee Notice and Leave Details

Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.

Learn more

Frequently asked

FMLA Leave Request Form Template — quick answers

Reviewed July 2026 Free download, PDF & DOCX

What is an FMLA leave request form?

An FMLA leave request form is an internal form an employee uses to notify an employer that the employee may need leave for a Family and Medical Leave Act reason. It helps collect the basic facts an employer needs to start the FMLA process, and DOL materials show that employers must then give required notices about eligibility, rights, responsibilities, and designation.

Why do you need an FMLA leave request form?

You need an FMLA leave request form to create a clear written record of the employee’s request, the expected dates, the type of leave, and whether certification may be needed. DOL explains that employers may use their own forms so long as they request only the basic information allowed by the FMLA regulations, and the employer notice process commonly involves WH-381 for eligibility and rights/responsibilities and WH-382 for designation.

When should you use an FMLA leave request form?

Use an FMLA leave request form when an employee needs job-protected leave for a possible FMLA reason and wants to notify the employer promptly. DOL guidance explains that eligible employees generally work for a covered employer, have at least 12 months of service, have worked at least 1,250 hours in the prior 12 months, and work at a site where the employer has at least 50 employees within 75 miles. DOL also states that eligible employees may take up to 12 workweeks in a 12-month period for qualifying reasons such as birth and bonding, adoption or foster placement, and certain family or medical reasons, and up to 26 workweeks in a single 12-month period for military caregiver leave.

How to write an FMLA leave request form?

Start with the employee’s identifying information, department, and supervisor, then add the expected leave dates, whether the leave is continuous or intermittent, and the general qualifying reason. DOL guidance also makes it useful to include enough information for the employer to understand that the leave may be FMLA-qualifying, along with any planned medical schedule, whether certification will follow, and whether the request relates to the employee’s own serious health condition, a family member’s serious health condition, a qualifying exigency, or military caregiver leave.

Can AI Lawyer help if employees, HR, and managers all need to review?

AI Lawyer can help by organizing the form into clear sections so each reviewer can find the relevant details quickly. It can also add internal reference fields, leave notes, and placeholders that make updates easier to track. A consistent structure helps reduce repeated edits and lowers the chance of missing key details like dates, type of leave, certification status, or return-to-work information before the request is submitted.

Similar templates