FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Arizona

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Notes: Arizona 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. Arizona-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. ARIZONA-SPECIFIC PROVISIONS

5A. No State FMLA Supplement

Arizona has not enacted a state family and medical leave statute applicable to private-sector employers. Private-sector employees in Arizona rely solely on the federal FMLA.

5B. Arizona State Employee Paid Parental Leave

The Arizona Department of Administration established a paid parental leave policy (effective September 2023) providing eligible state government employees up to 12 weeks of paid parental leave following the birth, adoption, or foster placement of a child.

☐ I am an Arizona state employee eligible for the state paid parental leave policy.
☐ I am a private-sector employee; only federal FMLA applies.

5C. Arizona Earned Paid Sick Time (Proposition 206)

Under A.R.S. §§ 23-371 to 23-381 (Fair Wages and Healthy Families Act / Proposition 206):

• Employers with 15+ employees: Employees accrue up to 40 hours of paid sick time per year.
• Employers with fewer than 15 employees: Employees accrue up to 24 hours per year.
• Accrual Rate: 1 hour per 30 hours worked.
• Qualifying Uses: Employee's own illness, family member care, public health emergencies, and domestic violence/sexual violence/stalking-related absences.

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

5D. No State Paid Family Leave Program

Arizona does not operate a state-funded paid family and medical leave (PFML) insurance program. FMLA leave is unpaid unless the employee substitutes accrued paid leave (vacation, sick, PTO) or the employer provides supplemental pay.

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 under the same terms as if the employee continued working (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 Arizona 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.R.S. §§ 23-371–23-381 (Proposition 206)
- Arizona Department of Administration — Family Leave Expansion