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.
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.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.