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FMLA Leave Request Form
Form for requesting family or medical leave under the Family and Medical Leave Act, which provides up to 12 weeks of unpaid, job-protected leave per year.
PDF TemplateUse the instructions below to complete this form
Instructions
Provide the reason for leave: serious health condition of employee or family member, birth or placement of a child, or qualifying military exigency. State the requested start and end dates. Indicate whether leave is continuous, intermittent, or reduced schedule. Attach medical certification (DOL Form WH-380). Employers with 50+ employees within 75 miles must provide FMLA leave. Employees must have worked 12 months and 1,250 hours to be eligible.