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.

Eligibility:

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 __________________________________

Employee Statement:

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.

Signature:_____________________________________________ Date:___________________

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 #: ____________________________________