FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Arkansas

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

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Arkansas-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 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.
• 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. ARKANSAS-SPECIFIC PROVISIONS

5A. No Mandatory State FMLA Supplement

Arkansas has not enacted a mandatory state family and medical leave statute for private-sector employers. Private-sector employees in Arkansas have only the rights guaranteed by the federal FMLA.

5B. Arkansas State Employee Paid Maternity Leave (Act 770 of 2023)

Under Act 770 of 2023, eligible Arkansas state employees may receive up to 12 consecutive weeks of paid leave for maternity reasons, including birth, adoption, or foster care placement of a child. This benefit is limited to state employees and does not extend to the private sector.

☐ I am an Arkansas state employee eligible for Act 770 paid maternity leave.
☐ I am a private-sector employee; only federal FMLA applies.

5C. Voluntary Paid Family Leave Insurance (A.C.A. § 23-86-501 et seq.)

Arkansas Act 850 of 2021 (codified at A.C.A. § 23-86-501 et seq.) authorizes private insurance carriers to offer voluntary paid family leave insurance products to Arkansas employers. Participation is not mandatory.

☐ Employer participates in a voluntary PFML insurance plan: ☐ Yes ☐ No ☐ Unknown

If yes, plan administrator: [________________________________]

5D. No State Paid Sick Leave Mandate

Arkansas does not require private employers to provide paid sick leave. However, employees may substitute accrued employer-provided paid leave (vacation, sick, PTO) for unpaid FMLA leave pursuant to 29 C.F.R. § 825.207.

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

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 — 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)).

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

10. BENEFITS CONTINUATION

• The employer must maintain group health insurance during FMLA leave (29 U.S.C. § 2614(c)).
• Employee must continue to pay their share of premiums.
• 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 applicable Arkansas law.
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.
☐ PENDING — Additional information or certification required.
☐ DENIED — Leave is not FMLA-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
- A.C.A. § 23-86-501 et seq. (Voluntary PFML Insurance)
- Arkansas Department of Shared Administrative Services — FMLA