Family Medical Leave Form Template
Request FMLA leave with all the information your employer and HR team need to process it.
Family and Medical Leave Act (FMLA) leave involves specific eligibility requirements and documentation obligations. This form guides employees through a complete FMLA request — and gives HR the information to determine eligibility and manage the leave compliantly.
The template covers the employee's name and department, the type of FMLA leave (employee's own serious health condition, family member care, military family leave, qualifying exigency), the start and end dates, intermittent leave details if applicable, and the healthcare provider certification requirement.
A well-managed FMLA process protects the employee's rights, the employer's compliance, and the employment relationship through a challenging time.
Employees who have worked for the employer for at least 12 months, have at least 1,250 hours in the past 12 months, and work at a location with 50 or more employees within 75 miles. Check your state — many states have broader family leave laws.
Up to 12 weeks of unpaid, job-protected leave per year for most qualifying reasons. Up to 26 weeks is available for military caregiver leave. Leave can be taken continuously, reduced schedule, or intermittently.
For foreseeable leave, at least 30 days' notice is required. For unforeseeable leave, notice must be given as soon as practicable — typically within 1 to 2 business days of when the need becomes known.
The employer may require a completed certification from the healthcare provider within 15 calendar days of the request. The certification describes the condition, its expected duration, and the need for leave.
If the employee is eligible and the reason qualifies, the employer must grant FMLA leave. Interfering with or retaliating against an employee exercising FMLA rights is illegal. However, the employer can require proper notice and certification.
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