FMLA Leave Request Form - Arizona
FAMILY AND MEDICAL LEAVE REQUEST FORM
State of Arizona
Federal Authority: 29 C.F.R. Part 825
Arizona coordination: Record any request to use available earned paid sick time or other applicable paid leave separately.
TABLE OF CONTENTS
- Employee Information
- Employer Information
- Type of Leave Requested
- Information for Employer Review
- Arizona Paid-Leave Coordination
- Leave Schedule and Dates
- Intermittent or Reduced Schedule Leave
- Medical Certification
- Return-to-Work Planning
- Pay and Benefits Questions
- Employee Acknowledgment and Signature
- Employer Response
1. EMPLOYEE INFORMATION
| Field | Entry |
|---|---|
| Full Legal Name | [________________________________] |
| Employee ID | [________________________________] |
| Job Title / Position | [________________________________] |
| Department | [________________________________] |
| Date of Hire | [__/__/____] |
| Work Location | [________________________________] |
| Direct Supervisor | [________________________________] |
| Phone Number | [________________________________] |
| Email Address | [________________________________] |
2. EMPLOYER INFORMATION
| Field | Entry |
|---|---|
| Employer Legal Name | [________________________________] |
| Employer Address | [________________________________] |
| City / State / ZIP | [________________________________] |
| FMLA Administrator / HR Contact | [________________________________] |
| Phone Number | [________________________________] |
| Email Address | [________________________________] |
3. TYPE OF LEAVE REQUESTED
Please indicate the reason for your FMLA leave request:
☐ Own Serious Health Condition — Leave requested for my own serious health condition
☐ Family Member Care — Leave requested to care for a spouse, child, or parent with a serious health condition
- Relationship to employee: [________________________________]
- Name of family member: [________________________________]
☐ Birth and Bonding — Leave requested for birth or bonding with a newborn child
☐ Adoption or Foster Care Placement — Leave requested for placement or bonding
☐ Qualifying Exigency — Leave requested because of a covered military family member's duty
- Type of exigency: [________________________________]
☐ Military Caregiver Leave — Leave requested to care for a covered servicemember or veteran with a serious injury or illness
- Relationship to servicemember: [________________________________]
☐ Other Leave Need for HR Review — Brief description: [________________________________]
4. INFORMATION FOR EMPLOYER REVIEW
This request supplies the facts needed for the employer's separate FMLA eligibility and designation review. It does not itself determine eligibility, the amount of available leave, or whether the requested reason qualifies.
| Question | Entry |
|---|---|
| Date the need for leave became known | [__/__/____] |
| Date and method of first notice to employer | [________________________________] |
| If notice was given later, reason | [________________________________] |
| Contact for follow-up about the schedule | [________________________________] |
5. ARIZONA PAID-LEAVE COORDINATION
Arizona earned paid sick time under A.R.S. § 23-372 and other available paid leave may need separate review. Record the request here; the employer should determine the applicable balance, qualifying use, and any concurrent FMLA designation under governing law and policy.
☐ Please review whether my available Arizona earned paid sick time can be used for this absence.
☐ Please review other available paid leave or benefits: [________________________________]
☐ I am an Arizona state employee and request review of any applicable state personnel leave policy.
Requested paid-leave dates or hours: [________________________________]
6. LEAVE SCHEDULE AND DATES
| Field | Entry |
|---|---|
| Requested Start Date | [__/__/____] |
| Requested End Date (estimated) | [__/__/____] |
| Total Weeks/Days Requested | [________________________________] |
| Expected Return-to-Work Date | [__/__/____] |
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:
| Field | Entry |
|---|---|
| Estimated Frequency | [________________________________] |
| Estimated Duration Per Episode | [________________________________] |
| Reduced Schedule (if applicable) | [________________________________] |
8. MEDICAL CERTIFICATION
☐ The employer requested certification; I will provide it through the designated confidential process by: [__/__/____]
☐ The employer has not requested certification.
☐ I need clarification of the requested certification or deadline.
If certification is requested by the employer, identify the form supplied:
- ☐ WH-380-E — Employee's serious health condition
- ☐ WH-380-F — Family member's serious health condition
- ☐ WH-384 — Qualifying exigency
- ☐ WH-385 — Current servicemember caregiver leave
- ☐ WH-385-V — Veteran caregiver leave
Date employer requested certification: [__/__/____]
Date employer specified for response: [__/__/____]
9. RETURN-TO-WORK PLANNING
Expected return date, if known: [__/__/____]
Contact for return-to-work planning: [________________________________]
Work schedule or accommodation question for HR, if any: [________________________________]
10. PAY AND BENEFITS QUESTIONS
Questions about paid leave, premiums, benefits, or payroll during the absence:
[____________________________________________________________]
11. EMPLOYEE ACKNOWLEDGMENT AND SIGNATURE
By signing below, I certify that:
- The information provided is true and complete to the best of my knowledge.
- I understand that the employer will review eligibility, certification, pay coordination, and designation separately and provide any required notices.
- I will respond to reasonable follow-up requests and update the employer if the requested dates change.
| Employee Signature | ________________________________________ |
| Printed Name | [________________________________] |
| Date | [__/__/____] |
12. EMPLOYER RESPONSE
☐ Request received on [__/__/____] by [________________________________].
☐ Eligibility and rights/responsibilities notices provided separately on [__/__/____].
☐ Certification requested separately on [__/__/____], if applicable.
☐ Designation notice provided separately on [__/__/____], after review.
| FMLA Administrator Signature | ________________________________________ |
| Printed Name / Title | [________________________________] |
| Date | [__/__/____] |
Notice or form identifiers used: [________________________________]
This employee request form does not replace the employer's eligibility, rights/responsibilities, or designation notices. DOL forms WH-381 and WH-382 are available as prototypes; the employer must provide the required notice content through the applicable process.
Sources and References:
About this template
- Last updated
- October 10, 2026
- Citations checked
- October 10, 2026
- Jurisdiction
- Arizona
- Category
- Employment & HR
Legal authority
- 29 C.F.R. § 825.110 (employee eligibility)
- 29 C.F.R. § 825.127 (military caregiver leave)
- 29 C.F.R. § 825.200 (qualifying reasons and amount of leave)
- 29 C.F.R. § 825.207 (paid leave substitution)
- 29 C.F.R. § 825.300 (employer notices)
- 29 C.F.R. § 825.305 (certification)
- A.R.S. § 23-372 (Arizona earned paid sick time accrual)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 10, 2026.
29 C.F.R. § 825.110(a) (checked October 10, 2026): "An eligible employee is an employee of a covered employer who: (1) Has been employed by the employer for at least 12 months, and (2) Has been employed for at least 1,250 hours of service during the 12-month period immediately preceding the commencement of the leave"
29 C.F.R. § 825.200(a) (checked October 10, 2026): "Except in the case of leave to care for a covered servicemember with a serious injury or illness, an eligible employee's FMLA leave entitlement is limited to a total of 12 workweeks of leave during any 12-month period"
29 C.F.R. § 825.127(a) (checked October 10, 2026): "Eligible employees are entitled to FMLA leave to care for a covered servicemember with a serious illness or injury."
29 C.F.R. § 825.207(a) (checked October 10, 2026): "However, under the circumstances described in this section, FMLA permits an eligible employee to choose to substitute accrued paid leave for FMLA leave. If an employee does not choose to substitute accrued paid leave, the employer may require the employee to substitute accrued paid leave for unpaid FMLA leave."
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