FMLA Leave Request Form - Alaska

FAMILY AND MEDICAL LEAVE REQUEST FORM

Alaska

To: [EMPLOYER / HR CONTACT]
From: [EMPLOYEE FULL NAME]
Date: [__/__/____]

I request leave for the reason and dates stated below. Please evaluate my request under each law and employer policy that applies to my employment and give me the required eligibility and designation information.

Employee and employer information

Reason for leave

Select each reason that applies. Federal FMLA and the Alaska Family Leave Act (AFLA) have different coverage and eligibility rules.

☐ My own serious health condition prevents me from performing my job.
☐ I need to care for my ☐ spouse ☐ child ☐ parent with a serious health condition.
☐ Pregnancy, childbirth, or bonding after the birth of my child.
☐ Placement of a child with me for adoption.
☐ Placement of a foster child with me (federal FMLA request).
☐ A qualifying exigency related to covered military service of my ☐ spouse ☐ child ☐ parent.
☐ Care for a covered servicemember with a serious injury or illness; my relationship is [RELATIONSHIP].
☐ Other leave under employer policy: [DESCRIBE].

Family member or servicemember name, if relevant: [NAME]

Reason and facts needed to identify the requested leave, without unnecessary diagnosis details: [DESCRIBE]

Requested schedule

If the dates or schedule change, I will notify [HR CONTACT] as soon as practicable.

Applicable leave and pay

Federal FMLA. Please determine eligibility under 29 U.S.C. § 2611(2), including the usual 12-month employment and 1,250-hour service conditions and the worksite rule for 50 employees within 75 miles. An eligible employee may have up to 12 workweeks for qualifying reasons in a 12-month period; covered servicemember care may allow up to 26 workweeks in a single 12-month period under 29 U.S.C. § 2612(a).

Alaska public employer leave. If my employer is the State of Alaska or a covered political subdivision, please separately determine AFLA eligibility under AS 39.20.500(b), (f) and 39.20.550(2), including the work schedule, service, employer-size, and small-facility conditions. The Alaska statute allows an eligible employee up to 18 workweeks in a 24-month period for a serious health condition, and 18 workweeks in a 12-month period for pregnancy and childbirth or adoption. A longer period may apply for pregnancy under AS 39.20.500(a), (b)(1). The AFLA reason and leave period must be assessed separately from federal FMLA.

☐ I request use of available paid leave during this absence: ☐ accrued Alaska paid sick leave ☐ vacation ☐ other [TYPE].
☐ I request unpaid leave to the extent permitted.
☐ Please tell me what paid leave substitution the employer will require, if any.

Alaska paid sick leave accrues at a minimum of one hour for 30 hours worked for covered employees of employers of any size. Under AS 23.10.066, the annual accrual and use limit is 56 hours for employers with 15 or more employees and 40 hours for employers with fewer than 15, unless the employer sets a higher limit. The exclusions in AS 23.10.069 may apply. Please confirm my available balance and whether the requested use qualifies.

Certification and attachments

☐ Supporting certification is attached.
☐ Please send the certification form or information required for this leave.
☐ I expect to provide requested certification by [__/__/____].

Attachments submitted: [LIST; DO NOT INCLUDE UNNECESSARY MEDICAL DETAILS IN THIS FORM]

Employee signature

I confirm that the information in this request is accurate to the best of my knowledge.

Signature: ______________________________

Printed name: [EMPLOYEE NAME]

Date: [__/__/____]

Employer receipt and response

Received by: [NAME / TITLE] Date: [__/__/____]

Federal FMLA eligibility: ☐ eligible ☐ not eligible ☐ pending review

AFLA eligibility, if applicable: ☐ eligible ☐ not eligible ☐ pending review ☐ not applicable

Paid leave balance and substitution terms: [________________________________]

Certification requested and due date, if applicable: [________________________________]

Leave designation and approved schedule: [________________________________]

HR contact and next communication date: [________________________________]

Employer representative signature: ______________________________ Date: [__/__/____]