Free FMLA Employee Request Form Template
This form is for employees to formally request leave under the Family and Medical Leave Act. It captures the reason for leave, whether it's continuous or intermittent, family member information, and the employee's acknowledgment of FMLA requirements.
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What the Form Covers
| Section | What it captures |
|---|---|
| Employee Information | Name, ID, department, job title, supervisor, date of request |
| Reason for Leave | Birth/adoption, employee health condition, family member health condition, military exigency, servicemember care |
| Leave Type | Continuous (full-time) or intermittent (blocks of time / reduced schedule) |
| Leave Dates | Start date, expected return date, intermittent frequency/duration |
| Family Member Info | Name, relation, care details (if leave is for a family member) |
| Certification | Acknowledgment that medical certification may be required |
| Employee Agreement | Understanding of eligibility verification, unpaid status, and health insurance obligations |
| HR/Management Section | Date received, eligibility determination, approval/denial, reason for denial |
Full Form Text
Employee Information
Employee Name: ___________________________
Employee ID: ___________________________
Department: ___________________________
Job Title: ___________________________
Manager/Supervisor Name: ___________________________
Date of Request: ___________________________
Reason for Leave (Check One)
- Birth of a child or placement of a child for adoption or foster care
- Serious health condition of employee
- Serious health condition of a family member (spouse, child, or parent)
- Qualifying exigency arising from a family member's military duty
- Caring for a family member who is a covered servicemember with a serious injury or illness
Leave Information
Type of Leave Requested:
- Continuous Leave (full-time, uninterrupted)
- Intermittent Leave (blocks of time or reduced schedule)
Start Date of Leave: ___________________________
Expected Return Date: ___________________________
If Intermittent Leave: Frequency: ___________ Duration: ___________
Family Member Information (if applicable)
Name: ___________________________
Relation to Employee: ___________________________
Care to be provided: ___________________________
Certification
I understand that I may be required to provide certification of my own or my family member's serious health condition. Failure to provide required certification may result in a delay or denial of FMLA leave.
Employee Agreement
I understand that this request may be subject to verification of eligibility under FMLA. I agree to provide additional documentation as requested. I understand that FMLA leave will be unpaid (unless covered by available paid time off) and that I must continue to make arrangements to maintain health insurance premiums during my leave.
Employee Signature: ___________________________
Date: ___________________________
For HR/Management Use Only
Date Request Received: ___________________________
Date of Eligibility Determination: ___________________________
Leave Approved: Yes / No
Reason for Denial (if applicable): ___________________________
HR/Manager Name: ___________________________
Signature: ___________________________
FMLA Eligibility Quick Reference
| Requirement | Threshold |
|---|---|
| Employment duration | At least 12 months with the employer |
| Hours worked | At least 1,250 hours in the 12 months before leave |
| Employer size | 50+ employees within a 75-mile radius |
FMLA provides up to 12 weeks of unpaid, job-protected leave per 12-month period (26 weeks for military caregiver leave). For a complete FMLA policy, see our FMLA policy template and FMLA compliance checklist.
Frequently Asked Questions
Common questions about FMLA leave requests.
For foreseeable leave (planned surgery, expected birth), employees must provide at least 30 days' notice. For unforeseeable situations, submit as soon as practicable.
Yes. Employers can request medical certification from a healthcare provider to support the leave request. The employee generally has 15 calendar days to provide it.
Yes, FMLA itself is unpaid. However, employers may require (or employees may choose) to substitute accrued paid leave (vacation, sick time) during the FMLA period.
Continuous leave is a single, uninterrupted block of time off. Intermittent leave is taken in separate blocks or on a reduced schedule (e.g., three days per week instead of five). Intermittent leave requires additional documentation of frequency and duration.
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