What This FMLA Leave Request Form Covers

This FMLA leave request form is designed to help employees formally request leave under the Family and Medical Leave Act (FMLA). It includes sections for employee information, details about the leave being requested, and a medical certification section, ensuring that all necessary information is provided for a smooth approval process.

When to Use a FMLA Request Template

Employees should use this FMLA request template when they need to take time off for personal health issues or to care for a family member with a serious health condition. Specific scenarios include needing to recover from surgery, caring for a newborn, or attending to a family member's medical emergencies.

What's Included in This Medical Leave Request Form

• Employee Information: This section collects essential details such as the employee's full name, department, and contact information.
• Leave Details: Employees must specify the type of leave, as well as the start and end dates of the requested leave period.
• Reason for Leave: A clear explanation of the reason for the leave is required, which helps HR understand the context of the request.
• Medical Certification: Employees may need to provide a medical certification to validate the need for leave, ensuring compliance with FMLA requirements.
• Employee Signature and Date: The form concludes with a signature section, confirming that the employee understands their rights under the FMLA.

Key Employee Leave Request Form Provisions

• Job Protection: The FMLA ensures that employees can take leave without fear of losing their job, which is crucial for those facing health challenges.
• Unpaid Leave: Employees are entitled to take up to 12 weeks of unpaid leave in a 12-month period for qualifying reasons, allowing them to focus on recovery or caregiving.
• Health Benefits Maintenance: During the leave, employees' health benefits must be maintained, ensuring they have access to necessary medical care.

Disclaimer: This template is for informational purposes only and does not constitute legal advice.