FMLA Request Form

Create a FMLA Request Form

Employee Name

Write your full name exactly as it appears on your legal documents, including your first, middle (if applicable), and last name. For example, if your name is John Michael Smith, write it as "John Michael Smith." This information is important for identifying you in any legal matters related to this document.

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What is a FMLA Request Form?

A Family Medical Leave Act (FMLA) Request Form is a legally recognized document used by employees to request a leave of absence for serious health conditions, to bond with a new child, or to care for a family member with a serious health condition. It is a critical component of the FMLA paperwork that guarantees employees up to 12 weeks of unpaid, job-protected leave per year.

Key Features

✓Allows employees to take necessary time off for medical and family reasons
✓Provides job security during the period of FMLA leave
✓Enforces the employer's obligation to maintain the employee's health benefits during leave
✓Gives employees the right to return to their job after the leave

Pros & Cons

Pros

✓Allows employees to take necessary time off for health and family reasons
✓Protects the job and health benefits of employees
✓Provides a clear framework and understanding of the leave process
✓Helps avoid legal complications

Cons

✗The FMLA leave is unpaid
✗Employees may struggle to cover the cost of living without a regular paycheck
✗Not all employers are covered, and not all employees are eligible for FMLA

Common Uses

Common Uses

✓When an employee is diagnosed with a serious health condition
✓When an employee's family member has a serious health condition
✓Upon the birth of an employee's child
✓Upon the placement of a child with the employee for adoption or foster care

FAQs

To apply for FMLA leave, you need to submit a FMLA Request Form to your employer. You should provide as much notice as possible, ideally at least 30 days if the need for leave is foreseeable.

To be eligible for FMLA leave, an employee must have worked for their employer for at least 12 months and have worked at least 1,250 hours during the 12 months prior to the start of the FMLA leave. The employer must also have 50 or more employees within a 75-mile radius.

If you meet the eligibility requirements and have a qualifying reason, your employer cannot deny your FMLA leave. However, they can require you to provide proof of your need for leave, such as a medical certification from a healthcare provider.

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About this document

The FMLA Request Form is used by employees to formally request leave under the Family and Medical Leave Act for qualifying reasons.

Create a FMLA Request Form

This document is designed to comply with the laws of all 50 states.

Published Jun 30, 2025
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Legal Notice: Comments are personal opinions and do not constitute legal advice. Always consult a qualified attorney for matters specific to your situation.