FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Alaska

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: Alaska Family Leave Act (AS 39.20.500–39.20.550)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Alaska-Specific Provisions
6. Leave Schedule and Dates
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. Employee Acknowledgment and Signature
12. Employer Response

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. TYPE OF LEAVE REQUESTED

Please indicate the reason for your leave request:

☐ Own Serious Health Condition — A serious health condition that renders the employee unable to perform essential job functions (29 U.S.C. § 2612(a)(1)(D))

☐ Family Member Care — To care for a spouse, child, or parent with a serious health condition (29 U.S.C. § 2612(a)(1)(C))
- Relationship to employee: [________________________________]
- Name of family member: [________________________________]

☐ Birth and Bonding — For the birth of a child and to bond with the newborn within 12 months of birth (29 U.S.C. § 2612(a)(1)(A))

☐ Adoption or Foster Care Placement — For placement of a child for adoption or foster care and to bond with the newly placed child (29 U.S.C. § 2612(a)(1)(B))

☐ Qualifying Exigency — For a qualifying exigency arising from a family member's covered active duty or call to active duty (29 U.S.C. § 2612(a)(1)(E))
- Type of exigency: [________________________________]

☐ Military Caregiver Leave — To care for a covered servicemember or veteran with a serious injury or illness (29 U.S.C. § 2612(a)(3))
- Relationship to servicemember: [________________________________]

4. FEDERAL FMLA OVERVIEW

• Eligibility: Employee must have worked for the employer for at least 12 months, with at least 1,250 hours of service during the preceding 12 months, at a worksite where the employer employs 50 or more employees within 75 miles (29 C.F.R. § 825.110).
• Leave Entitlement: Up to 12 workweeks of unpaid, job-protected leave in a 12-month period for qualifying reasons.
• Military Caregiver Leave: Up to 26 workweeks in a single 12-month period (29 U.S.C. § 2612(a)(3)).
• Notice Requirement: At least 30 days' advance notice when foreseeable; as soon as practicable when not foreseeable (29 C.F.R. §§ 825.302–303).

5. ALASKA-SPECIFIC PROVISIONS

5A. Alaska Family Leave Act (AFLA) — Public Employers Only

Applicability: The Alaska Family Leave Act (AS 39.20.500–39.20.550) applies to employers that are the State of Alaska or its political subdivisions.

Leave Entitlement Under AFLA:
- Up to 18 weeks of family leave in a 12-month period (or 24-month period, depending on the employer's designated leave year).
- AFLA leave may run concurrently with federal FMLA leave where both apply.

Qualifying Reasons Under AFLA:
- Birth or adoption of a child
- Placement of a foster child
- Serious health condition of the employee
- Serious health condition of the employee's spouse, child, or parent

☐ Employee is employed by a public employer covered by AFLA.
☐ Employee is employed by a private-sector employer (AFLA does not apply).

5B. Alaska Paid Sick Leave (AS 23.10.066–23.10.069)

• Accrual: 1 hour per 30 hours worked.
• Employees may use accrued paid sick leave to substitute for unpaid FMLA leave.

☐ Employee elects to use accrued Alaska paid sick leave during FMLA leave.
☐ Employee does not elect to use paid sick leave at this time.

5C. No State Paid Family Leave Program

Alaska does not operate a state-funded paid family and medical leave (PFML) insurance program. FMLA leave in Alaska is unpaid unless the employee substitutes accrued paid leave.

6. LEAVE SCHEDULE AND DATES

Employer's 12-Month Leave Period Method: [________________________________]

FMLA Leave Already Used This Period: [____] weeks [____] days

FMLA Leave Remaining: [____] weeks [____] days

AFLA Leave Already Used (if applicable): [____] weeks [____] days

AFLA Leave Remaining (if applicable): [____] weeks [____] days

7. INTERMITTENT OR REDUCED SCHEDULE LEAVE

☐ I am not requesting intermittent or reduced schedule leave.

☐ I am requesting intermittent or reduced schedule leave.

If intermittent or reduced schedule leave is requested:

8. MEDICAL CERTIFICATION

☐ Medical certification is attached (DOL Form: [________________________________])

☐ Medical certification will be provided by: [__/__/____]

☐ Medical certification is not required for this leave type

Certification Form Required:
- ☐ WH-380-E — Employee's Serious Health Condition
- ☐ WH-380-F — Family Member's Serious Health Condition
- ☐ WH-384 — Qualifying Exigency for Military Family Leave
- ☐ WH-385 — Serious Injury or Illness of a Current Servicemember
- ☐ WH-385-V — Serious Injury or Illness of a Veteran

9. JOB RESTORATION RIGHTS

Upon return from FMLA leave, the employee is entitled to be restored to the same or an equivalent position with equivalent pay, benefits, and terms of employment (29 U.S.C. § 2614(a)).

Under the AFLA (if applicable), public employees are entitled to restoration to the prior position or a comparable position (AS 39.20.520).

☐ Employee is designated as a "key employee" under 29 U.S.C. § 2614(b).

10. BENEFITS CONTINUATION

• The employer must maintain group health insurance under the same terms during FMLA leave (29 U.S.C. § 2614(c)).
• Employee must continue to pay their share of premiums during leave.
• Failure to return may allow employer to recover its share of premiums, subject to exceptions (29 C.F.R. § 825.213).

11. EMPLOYEE ACKNOWLEDGMENT AND SIGNATURE

By signing below, I certify that:

1. The information provided is true and complete to the best of my knowledge.
2. I understand my rights and obligations under federal FMLA and, if applicable, the Alaska Family Leave Act.
3. I understand that medical certification may be required.
4. I understand that misrepresentation may result in disciplinary action, up to and including termination.

12. EMPLOYER RESPONSE

☐ APPROVED — Leave is designated as FMLA-qualifying (and/or AFLA-qualifying).
☐ PENDING — Additional information or certification required.
☐ DENIED — Leave is not FMLA/AFLA-qualifying. Reason: [________________________________]

Notices Provided:
- ☐ WH-381 (Eligibility/Rights & Responsibilities Notice) — Date: [__/__/____]
- ☐ WH-382 (Designation Notice) — Date: [__/__/____]

This form does not replace U.S. Department of Labor FMLA forms. Employers must still issue all required DOL notices.

Sources and References:
- U.S. Department of Labor — FMLA
- 29 U.S.C. §§ 2601–2654
- Alaska Family Leave Act (AS 39.20.500–39.20.550)
- Alaska Paid Sick Leave (AS 23.10.066–23.10.069)