Template · Time off and attendance
FMLA leave request form
In short
An FMLA request form is the document an employee uses to tell their employer they need family or medical leave, and that HR uses to start the FMLA process. It records the reason, expected dates, whether leave is continuous or intermittent, and use of paid leave, then tracks the eligibility notice, certification and designation the law requires.
Family and Medical Leave Request template
Family and Medical Leave Request
Use this form to request leave for your own serious health condition, a family member's serious health condition, the birth or placement of a child, or military family needs. You do not need to describe a diagnosis on this form. Return it to [HR Name, Email] at least 30 days before leave when the need is foreseeable, or as soon as you can. HR will reply within 5 business days with your eligibility and next steps. Questions: [HR Phone].
Employee information
- Employee name
- Employee ID
- Job title
- Department and work location
- Supervisor
- Personal phone
- Personal email (for notices during leave)
- Date of this request
Reason for leave
- I am requesting leave for
- My own serious health condition, including pregnancy-related incapacity or prenatal careTo care for my spouse, child or parent with a serious health conditionBirth of my child and bonding with the newbornPlacement of a child with me for adoption or foster care, and bondingA qualifying exigency arising from my spouse, child or parent's military deploymentTo care for a covered servicemember with a serious injury or illness (I am their spouse, child, parent or next of kin)
- If caring for a family member: their name and relationship to you
- Expected or actual date of birth or placement (if applicable)
- Brief description of the need for leave (no diagnosis needed)
Timing and schedule
- Type of leave
- Continuous (a single block of time)Intermittent (separate periods, for example flare-ups or treatments)Reduced schedule (fewer hours per day or week)Combination
- First day of leave
- Expected return date
- For intermittent leave: expected frequency and length (for example 1 to 2 days a month; 4 hours every other Friday)
- For reduced schedule: proposed hours and days
- Have you scheduled treatment so as to limit disruption where medically possible?
- YesNot applicableWould like to discuss with HR
- Is this leave foreseeable?
- Yes: 30 days' notice givenYes: less than 30 days' notice (explain)No: unexpected need
- If less than 30 days' notice: reason
Paid leave and benefits
- Use of paid leave during FMLA leave (subject to company policy)
- Use accrued PTO / vacationUse accrued sick leaveApply for short-term disabilityApply for state paid family or medical leaveTake unpaid leaveNot sure: please advise
- How I will pay my share of health premiums during any unpaid leave
- Payroll deduction from any paid leaveDirect payment to the companyPlease advise
- Has this leave been reported as a work-related injury (workers' compensation)?
- NoYes: claim number below
- Workers' compensation claim number
Employee acknowledgment
- I understand HR may ask for a medical or military certification and that I will generally have at least 15 calendar days to return it.
- I will tell HR as soon as possible if my dates or schedule change, and I will follow the normal call-in procedure for intermittent absences, stating that the absence is FMLA-related.
- I understand that a fitness-for-duty certification may be required before returning from leave for my own serious health condition, if I am told in advance.
- Employee signature
- Date
HR use only: eligibility
- Date the company first learned of the possible FMLA need
- Months of service (needs 12, not necessarily consecutive)
- Hours worked in the 12 months before leave starts (needs 1,250)
- 50 or more employees within 75 miles of worksite
- YesNo
- FMLA leave already used in current 12-month period (weeks or hours)
- Eligibility and rights and responsibilities notice sent (date, within 5 business days)
- Employee eligible?
- EligibleNot eligible: reason given in notice; check state leave, ADA and company leave
HR use only: certification and designation
- Certification requested
- Employee health conditionFamily member health conditionQualifying exigencyMilitary caregiverNot required (for example proof of birth only, or not requested)
- Certification due date (at least 15 calendar days from request)
- Certification received date / complete and sufficient?
- Designation notice sent (date, within 5 business days of enough information)
- Designated
- Approved as FMLA leaveApproved in partNot FMLA-qualifying: other leave reviewedPending more information
- Amount of leave designated (weeks, days or hours)
- State leave running at the same time
- Paid leave substituted and pay code
- Benefits team notified to maintain health coverage
- Supervisor told of dates only (no medical details)
- HR representative
- HR signature
How to use this template
- Give employees the form as soon as they mention a possible need for family or medical leave, or as soon as a manager learns of one; the employee does not need to say 'FMLA' for your obligations to start.
- Employee completes the reason, dates, leave pattern and paid leave choices, and signs the acknowledgment.
- HR checks eligibility (12 months of service, 1,250 hours, 50 employees within 75 miles) and sends the eligibility and rights notice within 5 business days.
- Where you require it, request certification on the appropriate Department of Labor form or your own equivalent, allowing at least 15 calendar days.
- Once you have enough information, send the designation notice within 5 business days, stating how much leave counts against the FMLA entitlement and any paid leave substituted.
- Set up tracking of hours used, benefits continuation and the expected return date, and file the form and medical documents separately from the personnel file.
Who the FMLA covers
The Family and Medical Leave Act applies to private employers with 50 or more employees in 20 or more workweeks in the current or prior calendar year, and to all public agencies and schools. An employee is eligible after 12 months with the employer (not necessarily in a row), 1,250 hours worked in the 12 months before leave starts, and working at a site with at least 50 employees within 75 miles.
Eligible employees get up to 12 workweeks of unpaid, job-protected leave in a 12-month period for their own serious health condition, a family member's serious health condition, birth or placement of a child and bonding, and qualifying exigencies tied to military deployment. Military caregiver leave allows up to 26 workweeks in a single 12-month period. Group health coverage continues on the same terms during leave, and the employee returns to the same or an equivalent job.
The request form is not the DOL form
The Department of Labor publishes optional forms for the employer's side of the process: notice of eligibility and rights and responsibilities (WH-381), designation notice (WH-382), and certification forms for the employee's health condition (WH-380-E), a family member's (WH-380-F), qualifying exigency (WH-384) and military caregiver leave (WH-385). It does not publish an employee request form. That is what this template fills: a consistent way for employees to ask, and for HR to log the dates that start the legal clock.
The date that matters most is when the company first learned of a possibly qualifying need. A supervisor hearing 'my mother had a stroke and I'll need time to care for her' counts. From then, the employer generally has 5 business days to send the eligibility notice. Train supervisors to pass these conversations to HR the same day, and give them the general leave request form for routine time off so they can tell the two apart.
Intermittent leave in hourly and shift-based teams
Intermittent leave is where most FMLA administration problems sit, particularly in contact centers, hospitals and plants. An employee certified for migraine flare-ups of 1 to 2 days a month can call out without notice and the absences are protected, but they still have to follow the normal call-in procedure unless circumstances make that impossible. Track intermittent leave in hours. An employee who normally works 40 hours a week has 480 hours of entitlement in the 12-month period; one who works 30 hours has 360.
Worked example: a customer service representative on a 40-hour schedule is certified for intermittent leave for a child's chronic asthma. Over six months she uses 11 full shifts of 8 hours and 6 partial days of 4 hours: 88 plus 24, or 112 hours. She has 368 hours left. None of those absences can count toward attendance points, and the employer may ask for recertification. The general rule is no more often than every 30 days and only in connection with an absence, but a significant change, such as absences well beyond the certified frequency, can justify an earlier request.
State leave, paid leave and the ADA
FMLA is unpaid, but employers may require, or employees may choose, to substitute accrued paid leave, following the employer's normal paid leave rules. Many states now run paid family and medical leave programs, and several have their own job-protected leave laws with lower thresholds than the FMLA. When both apply, they usually run at the same time, but not always, so check the rules for each state.
An employee who is not FMLA-eligible, or who has used all 12 weeks, may still be entitled to leave as a reasonable accommodation under the ADA, or to pregnancy-related accommodation under the Pregnant Workers Fairness Act. Never close a request just because FMLA does not apply. When paid sick leave runs at the same time, the terms in your sick leave policy control how it is used.
Common mistakes
- Waiting for the employee to say 'FMLA' before starting the process.
- Missing the 5-business-day deadlines for eligibility and designation notices, which can lead to interference claims.
- Asking for the diagnosis, or letting supervisors see certification forms. Keep medical records confidential and separate.
- Counting FMLA absences toward attendance points or performance ratings.
- Designating leave retroactively without telling the employee or without a valid reason.
- Forgetting the return. Plan reinstatement, and use a return to work form if a fitness-for-duty certification was required and announced in advance.
This page is general information, not legal advice, and state rules differ. Large or complex cases benefit from counsel or a leave administration specialist.
Frequently asked questions
Is there an official FMLA request form?
No. The Department of Labor publishes optional notices and certification forms for employers, but not an employee request form. Employers create their own, and an employee can request leave verbally or in writing without any form at all.
What is the difference between a leave of absence request form and an FMLA request form?
A leave of absence request form covers any extended time off, protected or not. An FMLA request form is built around FMLA's reasons, eligibility test, notice deadlines and certification steps. Many employers use one form with an FMLA section.
How much notice does an employee need to give for FMLA leave?
At least 30 days when the leave is foreseeable, such as a planned surgery or birth. When it is not foreseeable, notice is due as soon as practicable, generally following the employer's usual call-in procedures.
How long does an employee have to return a medical leave certification?
At least 15 calendar days after the employer requests it, and longer if the employee is making diligent, good-faith efforts but cannot get it in time.
What should a leave of absence letter from an employee say?
The reason in general terms (own health, family member's health, new child, military family need), the expected start and return dates, whether leave is continuous or intermittent, and contact details during leave. The employee does not need to state a diagnosis.
Can an employer deny an FMLA request?
An employer can deny FMLA designation if the employee is not eligible, the reason does not qualify, the entitlement is used up, or required certification is not provided. It should still check whether state law, the ADA or company policy gives the employee leave.