The FMLA Leave Request Form is a crucial document that employees use to formally request leave under the Family and Medical Leave Act (FMLA). This form allows individuals to take time off for significant life events, such as the birth or adoption of a child, or to care for a family member with a serious health condition. If you need to request FMLA leave, fill out the form by clicking the button below.
The Family and Medical Leave Act (FMLA) Leave Request Form is a vital document for employees seeking to take time off for specific family or medical reasons. This form must be completed and submitted to the Human Resource Office to initiate the leave process. Employees begin by providing their name and department, followed by the dates they wish to take leave. The form allows for requests related to various circumstances, such as the birth of a child, adoption, or caring for a family member with a serious health condition. Additionally, employees can request intermittent or reduced-schedule leave, specifying the times and reasons for their absence. Another important aspect of the form is the option to substitute paid leave, allowing employees to utilize vacation or sick hours during their time away. Finally, employees must provide contact information, ensuring that they can be reached during their leave. With the right information filled out, the process can be straightforward, helping employees navigate their rights and responsibilities under the FMLA.
FMLA LEAVE REQUEST FORM
(The following request is to be completed and returned to the Human Resource Office)
EMPLOYEE REQUEST
Employee’s Name
Employee’s Department
Date
Request for Full-Time Leave
I request a leave of absence from
(date) to
(date)
for the following reason:
For birth of my child and/or to care for the newborn child.
For placement of a child with me for adoption or foster care.
To care for my (circle one): spouse, child or parent with a serious health condition. Name:
My own serious health condition.
For another reason. (Please specify):
Request for Intermittent or Reduced-Schedule Leave
I request intermittent leave or reduced-schedule leave at the following times:
Schedule:
Reason:
Substitution of Paid Leave
I request to use (check all that apply):
Paid Vacation
Sick Hours
Location During Leave
Other
I can be reached at the following address and phone number during my leave:
Employee Signature
Approved By
© The Personnel Advisor
907
After completing the FMLA Leave form, submit it to the Human Resource Office for processing. Ensure all necessary information is accurate to avoid delays in approval.
What is the FMLA Leave Form used for?
The FMLA Leave Form is a request that employees use to apply for leave under the Family and Medical Leave Act (FMLA). This form allows employees to formally request time off for specific reasons, such as the birth of a child, adoption, caring for a family member with a serious health condition, or addressing their own serious health condition. By completing this form, employees notify their employer of their need for leave and the reasons behind it.
Who is eligible to take FMLA leave?
To be eligible for FMLA leave, an employee must work for a covered employer, have worked for that employer for at least 12 months, and have logged at least 1,250 hours of service in the past 12 months. Additionally, the employee must work at a location where the employer has 50 or more employees within a 75-mile radius. If these criteria are met, the employee can take up to 12 weeks of unpaid leave within a 12-month period for qualifying reasons.
What information do I need to provide when filling out the form?
When completing the FMLA Leave Form, you will need to provide your name, department, and the specific dates you are requesting for leave. Additionally, you must indicate the reason for your leave by selecting from the options provided, such as caring for a newborn, adopting a child, or addressing a serious health condition. If you are requesting intermittent leave, you should specify the schedule and reason for the leave as well.
Can I use paid leave while on FMLA leave?
Yes, you can choose to use paid leave while on FMLA leave. The form allows you to indicate if you wish to substitute any paid vacation or sick hours during your time off. This can help you maintain some income while you are away from work. However, it’s important to check your employer’s policies regarding paid leave and how it interacts with FMLA leave.
How do I submit the FMLA Leave Form?
Once you have completed the FMLA Leave Form, you should submit it to your Human Resources Office. It’s best to do this as early as possible to allow your employer time to process your request. Depending on your employer’s policies, you may need to submit the form in person, via email, or through an online portal. Always keep a copy of the submitted form for your records.
What happens after I submit my FMLA Leave Form?
After you submit your FMLA Leave Form, your employer is required to respond to your request. They will review the information you provided and may ask for additional documentation to support your leave request, especially if it is for a serious health condition. Once your leave is approved, you will receive confirmation of your leave dates and any additional information regarding your rights and responsibilities while on leave.
Filling out the FMLA Leave Request Form can be straightforward, but mistakes can lead to delays or denials. Here are seven common errors to avoid.
First, many individuals forget to provide their full name and department. This information is crucial for Human Resources to process the request efficiently. Omitting these details can cause confusion and slow down the approval process.
Second, some people neglect to specify the exact dates for their leave. It’s essential to clearly indicate when the leave will start and end. Without this information, HR may not be able to determine if the request meets FMLA guidelines.
Another frequent mistake is failing to select the correct reason for the leave. The form offers several options, including caring for a newborn or a serious health condition. Make sure to circle the appropriate reason. Misidentifying the reason can lead to misunderstandings about eligibility.
Additionally, individuals often forget to specify details for intermittent or reduced-schedule leave when applicable. If you plan to take leave in smaller increments, clearly outline your schedule and the reason for this type of leave. Lack of clarity can result in complications later on.
Some employees overlook the section regarding the substitution of paid leave. It’s important to indicate which paid leave options you wish to use. This helps HR manage your leave effectively and ensures you receive the appropriate compensation during your absence.
Moreover, failing to provide a reliable contact method during your leave can create issues. Ensure you list an address and phone number where you can be reached. This allows HR to contact you if they need additional information regarding your request.
Finally, remember to sign the form before submission. An unsigned form is considered incomplete and may be returned to you, causing unnecessary delays. Taking the time to double-check your form can save you from these common pitfalls.
When applying for leave under the Family and Medical Leave Act (FMLA), several other forms and documents may be required to support your request. Each of these documents serves a specific purpose in the leave application process. Below is a list of commonly used forms and documents that often accompany the FMLA Leave form.
Understanding the various forms and documents associated with the FMLA leave process can help ensure a smoother experience. Each document plays a crucial role in providing necessary information and supporting the leave request. Be sure to gather all required paperwork before submitting your FMLA leave request to facilitate timely processing.
The Family and Medical Leave Act (FMLA) Leave Form shares similarities with several other important documents used for employee leave and benefits. Each of these documents serves a unique purpose while addressing employee rights and responsibilities. Below are six documents that are comparable to the FMLA Leave Form:
When filling out the FMLA Leave form, it's crucial to get it right. Here’s a list of things you should and shouldn't do:
Completing the form accurately is essential for a smooth leave process. Pay attention to these guidelines to ensure everything goes as planned.
Understanding the Family and Medical Leave Act (FMLA) Leave form can be challenging. Here are five common misconceptions that can lead to confusion.
Being aware of these misconceptions can help employees navigate the FMLA process more smoothly and ensure they receive the leave they need.
Filling out the FMLA Leave form accurately is crucial for ensuring that your request is processed smoothly. Here are key takeaways to consider:
Understanding these points can facilitate a smoother experience when navigating your FMLA leave request.