FMLA Leave Request

Date:

Employee Name:

Home Address:

Social Security Number:

Job Title:

Department:

Manager:

Leave Eligibility

In order to be eligible for 12 weeks of unpaid leave under the FMLA every 12 months you must meet BOTH of the following requirements:

1) Â Â Â Â Â You have worked at {INSERT COMPANY NAME} for 12 months or more (12 months does not need to be consecutive).

2) Â Â Â Â Â You have accrued a minimum of 1250 hours (approximately 8 months based on a 40 hour work week or 1 year based on a 25 hour work week) in the last 12 calendar months.

Please select one of the following:

Yes, I meet both requirements

No, I do not meet both requirements

Previous Leave Information

Have you ever taken leave under the Family and Medical Leave Act? Â

YES Â Â Â Â NO

If yes, please provide the dates of leave and the reason for the leave below.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever taken a leave that was not under the Family and Medical Leave Act?

YES Â Â Â Â NO

If yes, please provide dates of leave and the reason for the leave below.

Reason For Leave Request

Select Â reason for leave request under the FMLA:

Â Â Â Â Â Â Â Â Â Â Â For a serious personal health condition:

Does your health condition require a 3 day absence from work and/or an overnight stay at a medical clinic? Â YES Â Â Â Â Â NO

Â Â Â Â Â Â Â Â Â Â Â Describe condition below:

Â Â Â Â Â Â Â Â Â Â Â __________________________________________________________________

Â Â Â Â Â Â Â Â Â Â Â To care for a spouse, child or parent with a serious health condition:

Â Â Â Â Â Â Â Â Â Â Â Name of family member: Â _________________________

Â Â Â Â Â Â Â Â Â Â Â Relationship to you: Â _____________________________

Â Â Â Â Â Â Â Â Â Â Â If the family member is a child, is he/she under 18 years of age?

YES Â Â Â Â Â NO

Does the family member´s condition require a 3 day absence from normal life activities (work, school, etc) and/or an overnight stay at a medical facility?

Â Â Â Â Â Â Â Â Â Â Â YES Â Â Â Â Â NO

Â Â Â Â Â Â Â Â Â Â Â Describe condition below:

Â Â Â Â Â Â Â Â Â Â Â __________________________________________________________________

Â Â Â Â Â Â Â Â Â To attend the birth, adoption, or foster placement of a child.

Â Â Â Â Â Â Â Â Â Â Â Provide expected date of birth, adoption, or foster placement.

Â Â Â Â Â Â Â Â Â Â Â __________________________________________________________________

Description of Requested Leave

Dates of requested leave: Â _________________________

Total leave time: Â ________________________________

Is this request for an intermittent leave? Â Â Â YES Â Â Â NO

If yes, describe below the proposed schedule.

Is this request for a reduced work hour leave? Â Â Â YES Â Â Â NO

If yes, describe below the proposed schedule.

________________________________________________________________________

Are you requesting that paid leave be substituted for unpaid FMLA leave?

YES Â Â Â Â Â NO

If yes, name the paid leave you wish to substitute.

________________________________________________________________________

Employee Statement

I agree to return to work on {ENTER DATE MM/DD/YYYY}. Â Should circumstances change, I agree to notify my employer {INSERT COMPANY NAME} in writing as soon as possible.

I agree to provide my employer with any requested medical certification that is permitted under the clauses of the Family and Medical Leave Act of 1993. Â I understand that my employer, {INSERT COMPANY NAME}, will continue to pay my health care benefits, but that payment for all other benefits will be suspended until I return to work. Â I understand that the continuation of my health care benefits is contingent upon my continue payment for my regular health care deductions.

I acknowledge that I have read and understood the Notification of Employee FMLA Rights given to me by my employer.

________________________

Print Name

________________________

Signature

________________________

Date

Â

For Office Use Only

General Employee Information

Start Date: Â {MM/DD/YYYY}

End Date: Â Â {MM/DD/YYYY}

Hours worked per day: Â ________________________

Days worked per week: ________________________

Total hours worked per week: ___________________

This schedule began on: Â {MM/DD/YYYY}

Leave Approval

Â Â Â Â Â Â Â Â Â Â Â Employee´s requested leave is approved.

Â Â Â Â Â Â Â Â Â Â Â 1) Â Select one of the following:

Intermittent Leave

Reduced Schedule Leave

Describe below:

______________________________________________________________________________________________________________________________________________________________________________________________________

2) Will the employee need to provide medical certification during the leave?

YES

If yes, describe below:

______________________________________________________________________________________________________________________________________________________________________________________________________

3) Return to work date: Â {MM/DD/YYYY}

Â Â Â Â Â Â Â Â Â Â Â Employee´s requested leave is denied.

Â Â Â Â Â Â Â Â Â Â Â Provide reason for refusal below.

Â Â Â Â Â Â Â Â Â Â Â __________________________________________________________________

Request approved/denied by:

________________________ Â Â Â Â Â Â Â Â Â Â Â _________________________ Â Â Â Â Â Â Â Â Â

Print Name Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Signature

________________________ Â Â Â Â Â Â Â Â Â Â Â _________________________

Position Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Date