Family and Medical Leave Request Form
March 10, 2008
This Family and Medical Leave Request form documents an employee’s request for time off for family or medical leave purposes. Employees are entitled to up to 12 weeks of unpaid, job-protected leave for certain medical or family needs. Eligibility is based on time worked, work schedule, and other factors. Advance notice is required. The employer reserves the right to deny/postpone leave for failure to give proper notice. The employee must provide, in writing, the dates, reasons, and expected return date. The supervisor and HR department must sign off on this request.
Employee: _______________________________________________ Date: _____________________ Job Title: ____________________________________ Supervisor: _____________________________ Employee ID #: ____________________________
Eligible employees are entitled to up to 12 weeks of unpaid, job-protected leave under the Family and Medical Leave Act (FMLA) for certain family and medical reasons. Submit this request form to your supervisor at least 30 days before the leave is to commence, when practicable. When submission of the request 30 days in advance is not practicable, submit the request as early as is practicable. The employer reserves the right to deny or postpone leave for failure to give appropriate notice when such denial/postponement would be permitted under federal or state law.
1. Yes No Counting any periods of time that you worked for the company (whether they were consecutive or not), have you worked for the company for a total of 12 months of more? (If “yes,” continue to next question. If “no,” stop here.)
2. Yes No During the past 12 months, have you worked at least 1,250 hours (approximately 8 months of 40-hour weeks or 1 year of 25-hour weeks)? (If “yes,” continue to next question. If “no,” stop here.) Have you previously received medical or family leave? If “yes”, provide information below:
Dates of leave:
From: ___________________________ To: _____________________________
Purpose of leave: _______________________________________________________________________ _______________________________________________________________________________
3. Yes No Have you taken any intermittent leave?
4. Yes No Have you taken time off from scheduled hours?
If “yes,” provide details: _________________________________________________________________ ______________________________________________________________________________
Reasons for Requesting Leave:
Leave must be granted for any of the following reasons:
• For a serious health condition that makes it unable for you to perform your job; • To care for your child, spouse, or parent who has a serious health condition; or • To care for your child after birth, adoption, or for placement for foster care.
I am requesting leave for the following reason:
Personal serious health condition
Serious health condition of:
Spouse Name: _______________________________________________________________ Child Name: ________________________________________________________________ Parent Name: ________________________________________________________________
Birth of a child
Expected delivery date is: _____________________________________________________
Adoption or placement of a child for foster care
Child’s name: _______________________________________________________________ Scheduled date of adoption or placement:_________________________________________
Dates of Leave Requested:
I request leave from ______________________________ to_________________________
I request intermittent leave according to the following schedule: ______________________________________________________________________________ ______________________________________________________________________________
I request a reduced schedule leave according to the following schedule: ______________________________________________________________________________ ______________________________________________________________________________
The total number of days of leave that I request is __________________________________
I agree to return to work on _________________________________. If circumstances change such that I will not be able to return to work on that date, I agree to inform my supervisor by submitting a NOTICE TO EMPLOYER OF CHANGES IN APPROVED MEDICAL OR FAMILY LEAVE form. I understand that my benefits will continue during my leave and that I will arrange to pay my share of applicable premiums.
To Be Completed By Supervisor:
Staff member was hired on __________________________________
He/she started in this department on ___________________________
Staff member is Full-time Part-time
Regular hours are _________ hrs on _________ days of the week for a total of _________ hours per week.
Schedule commenced on _________ (If there was an earlier schedule, list below.)
Are there 50 or more staff members at or within 75 miles of the worksite where the staff member works? Yes No
Has the workforce been this large for at least 12 months? Yes No
How will the staff member’s duties and responsibilities in your unit be handled during his or her leave of absence? ______________________________________________________________________________ ______________________________________________________________________________
Employee has previously requested family or medical leave on ___________________________ Leave taken from ______________ to ______________ Total time taken ___________________ Supervisor: _____________________________________ Title: __________________________ Date: ________________________ Telephone #: ____________________________________