FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Alabama

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Notes: Alabama has no private-sector state FMLA supplement; federal FMLA governs

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Alabama-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 FMLA leave request:

☐ Own Serious Health Condition — A serious health condition that renders the employee unable to perform the essential functions of their position (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 within 12 months of placement (29 U.S.C. § 2612(a)(1)(B))

☐ Qualifying Exigency — For a qualifying exigency arising from the employee's spouse, child, or parent being on covered active duty or called to covered active duty in the Armed Forces (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 to care for a covered servicemember with a serious injury or illness (29 U.S.C. § 2612(a)(3)).
• Notice Requirement: When foreseeable, the employee must provide at least 30 days' advance notice. When not foreseeable, notice must be given as soon as practicable (29 C.F.R. § 825.302–303).

5. ALABAMA-SPECIFIC PROVISIONS

No State FMLA Supplement for Private Employers. Alabama has not enacted a state family or medical leave statute applicable to private-sector employers. Private-sector employees in Alabama have only the rights guaranteed by the federal FMLA.

Alabama Public Employee Paid Parental Leave Act (Act 2025-81):
- Effective July 1, 2025, eligible Alabama state employees, K–12 public school educators, and community college employees may receive paid parental leave.
- Birthing parent: up to 8 weeks of paid leave at 100% of base pay following birth, stillbirth, or qualifying miscarriage.
- Non-birthing parent: up to 2 weeks of paid parental leave.
- Adoption (child age 3 or younger): one eligible parent receives 8 weeks; the other eligible parent receives 2 weeks.
- This benefit does not extend to private-sector employees.

☐ I am a public employee eligible for Alabama Act 2025-81 paid parental leave.
☐ I am a private-sector employee; only federal FMLA applies.

Voluntary Paid Family Leave (Private Sector):
Alabama permits employers to purchase voluntary Paid Family Medical Leave coverage through private insurers. Check with your employer whether such coverage is available.

☐ Employer offers voluntary PFML insurance: ☐ Yes ☐ No ☐ Unknown

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

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 — Certification of Health Care Provider for Employee's Serious Health Condition
- ☐ WH-380-F — Certification of Health Care Provider for Family Member's Serious Health Condition
- ☐ WH-384 — Certification of Qualifying Exigency for Military Family Leave
- ☐ WH-385 — Certification for Serious Injury or Illness of a Current Servicemember
- ☐ WH-385-V — Certification for 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 position or an equivalent position with equivalent pay, benefits, and other terms and conditions of employment (29 U.S.C. § 2614(a)).

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

10. BENEFITS CONTINUATION

During FMLA leave, the employer must maintain the employee's group health insurance coverage under the same terms and conditions as if the employee had continued to work (29 U.S.C. § 2614(c)).

• Employee's share of health insurance premiums must continue to be paid during leave.
• Failure to return from FMLA leave may result in the employer recovering its share of health insurance premiums paid during the leave, unless the failure to return is due to a continuation, recurrence, or onset of a serious health condition or other circumstances beyond the employee's control (29 C.F.R. § 825.213).

11. EMPLOYEE ACKNOWLEDGMENT AND SIGNATURE

By signing below, I certify that:

1. The information provided in this request is true and complete to the best of my knowledge.
2. I understand my rights and obligations under the FMLA and applicable Alabama law.
3. I understand that I may be required to provide medical certification supporting this leave request.
4. I understand that misrepresentation or fraud in connection with this leave request may result in disciplinary action, up to and including termination.

12. EMPLOYER RESPONSE

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

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

This form does not replace U.S. Department of Labor FMLA forms. Employers must still issue all required DOL notices. This template is for informational purposes only and must be reviewed by qualified legal counsel before use.

Sources and References:
- U.S. Department of Labor — FMLA
- 29 U.S.C. §§ 2601–2654
- 29 C.F.R. Part 825
- Alabama Act 2025-81 — Public Employee Paid Parental Leave