Family Medical Leave Request Form

FMLA provides 12 weeks of job-protected leave in a 12 month period to eligible employees. To qualify for FMLA you must have worked at least 12 months (need not be consecutive), and also have worked at least 1,250 hours during the 12 months prior to the start of the FMLA leave.

Please fill out the request below.

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Family and Medical Leave

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Family Medical Leave Request Form

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First and Last Name:*

Email:*

Work Phone Number:*

Employee ID:

Department Name: **

Supervisor:*

Job Title:*

Hire Date:*

Please select the applicable reason for this request.:*

Serious health condition that makes the employee unable to perform the essential functions of his/her job.

To care for the employee’s child after birth, or placement for adoption or foster care.

Incapacity due to pregnancy, prenatal medical care or child birth

To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition.

Qualified exigencies for an eligible employee whose close family member is on active duty.

A leave of absence is requested from (start-end date):*

Have you been on FMLA within the last year?: **

Yes

What type of leave will you need?: **

A single block of time

An intermittent/reduced work schedule

If intermittent/reduced schedule, please explain:

Family Medical Leave Request Form

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