FMLA Leave Request Form

FAMILY AND MEDICAL LEAVE ACT

LEAVE REQUEST & EMPLOYER NOTICE WORKSHEET

(29 U.S.C. §§ 2611–2617; 29 C.F.R. Part 825)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Leave Request and Administration
IV. Coverage and Eligibility Review
V. Ongoing Responsibilities
VI. Certification, Benefits, and Remedies
VII. Preservation of Rights
VIII. Enforcement Information
IX. General Provisions
X. Receipt Block
Exhibit A – Employee Leave Election Schedule
Exhibit B – Optional-Use DOL FMLA Forms
Exhibit C – California State Law Addendum (CFRA/PDL/PFL)

I. DOCUMENT HEADER

1. Parties
   1.1 Employer: [EMPLOYER LEGAL NAME], a [STATE] [corporation/LLC/other] (the “Employer”).
   1.2 Employee: [EMPLOYEE LEGAL NAME], [job title] (the “Employee”).

2. Effective Date (the “Effective Date”): [DATE].

3. Recitals
   A. The Employee is requesting leave that may qualify under the Family and Medical Leave Act (the “Act”).
   B. The Employer will determine employer coverage, employee eligibility, and whether the leave qualifies after providing the notices required by 29 C.F.R. § 825.300.
   C. This worksheet records the request and required notices. It does not waive, reduce, or expand any right under the Act or other applicable law.

II. DEFINITIONS

(Definitions appear alphabetically; capitalized terms used but not defined herein have the meanings assigned in the Act or 29 C.F.R. Part 825.)

“Act” means the Family and Medical Leave Act and its implementing regulations in 29 C.F.R. Part 825.
“Applicable Law” means all federal, state, and local statutes, regulations, and ordinances governing this leave request.
“Certification” means information permitted by the FMLA regulations to support a qualifying reason for leave, which may be supplied on an optional DOL form or in another permitted format.
“Covered Service-Member Leave” has the meaning set forth in 29 U.S.C. § 2612(a)(3).
“FMLA Leave” means job-protected leave provided under the Act.
“Intermittent Leave” means non-continuous leave taken in separate blocks of time for a single qualifying reason.
“Leave Period” means the period identified in Section 3.1.
“Qualifying Exigency” has the meaning set forth in 29 U.S.C. § 2612(a)(1)(E).
“Serious Health Condition” has the meaning set forth in 29 U.S.C. § 2611(11).

III. LEAVE REQUEST AND ADMINISTRATION

3.1 Leave Request

(a) Type of Leave Requested (check one):

☐ Birth/bonding with child

☐ Placement for adoption/foster care

☐ Employee’s Serious Health Condition

☐ Care for a spouse, son, daughter, or parent with a Serious Health Condition

☐ Qualifying Exigency

☐ Covered Service-Member Leave for a spouse, son, daughter, parent, or next of kin

(b) Anticipated Leave Period: From [START DATE] through [END DATE].

(c) Leave Schedule: ☐ Continuous ☐ Intermittent ☐ Reduced Schedule

(d) Estimated Total Workdays/Hours Absent: [NUMBER].

3.2 Documentation & Certifications

(a) If the Employer requests Certification, the Employee ordinarily must provide it within fifteen (15) calendar days after the request, unless doing so is not practicable despite diligent, good-faith efforts or the Employer allows more time.

(b) If a submitted Certification is incomplete or insufficient, the Employer shall identify the deficiency in writing and ordinarily allow seven (7) calendar days to cure it before denying FMLA protection on that basis. See 29 C.F.R. § 825.305.

3.3 Substitution of Paid Leave

☐ The Employee elects to substitute accrued paid [vacation/PTO/sick] leave. ☐ The Employer requires substitution under its normal paid-leave policy. ☐ No substitution applies. When substitution applies, paid leave runs concurrently with otherwise unpaid FMLA Leave, subject to the normal terms of the paid-leave policy. Failure to satisfy the paid-leave policy may affect pay but does not eliminate otherwise available unpaid FMLA Leave. See 29 C.F.R. § 825.207.

3.4 Maintenance of Benefits

(a) The Employer shall maintain group health plan coverage on the same terms as if the Employee had continued to work, pursuant to 29 U.S.C. § 2614(c).

(b) The Employee shall remit the employee-portion of premiums on or before [DATE/INTERVAL].

3.5 Return-to-Work

(a) ☐ The Employer's uniformly applied policy requires a fitness-for-duty certification for leave taken because of the Employee's own Serious Health Condition. This requirement and any essential-functions requirement must be stated in the Designation Notice. No fixed two-business-day deadline applies. See 29 C.F.R. § 825.312.

(b) The Employer shall restore the Employee to the same or an equivalent position as required by 29 U.S.C. § 2614(a), subject to lawful limitations, including the key-employee provisions and circumstances in which the Employee would not otherwise have remained employed.

3.6 Employer Notices

(a) Eligibility and Rights-and-Responsibilities Notice issued: ☐ WH-381 ☐ equivalent, on [DATE].

(b) Designation Notice issued: ☐ WH-382 ☐ equivalent, on [DATE].

(c) Employer determination: ☐ Eligible ☐ Not eligible because [________________] ☐ Pending Certification or other information.

IV. COVERAGE AND ELIGIBILITY REVIEW

4.1 Employee Eligibility — Employer Review

(a) Employed by Employer for at least twelve (12) months, subject to the break-in-service rules: ☐ Yes ☐ No.

(b) At least 1,250 hours of service during the twelve (12) months immediately before leave begins, unless a special rule applies: ☐ Yes ☐ No.

(c) Employed at a worksite where Employer employs at least fifty (50) employees within seventy-five (75) miles: ☐ Yes ☐ No.

4.2 Employer Coverage — Separate Review

☐ Private employer with at least fifty (50) employees for each working day during at least twenty (20) calendar workweeks in the current or preceding calendar year.

☐ Public agency, covered without regard to employee count.

☐ Public or private elementary or secondary school, covered without regard to employee count.

☐ Not covered under the federal Act; review state or local leave law.

4.3 Information Provided by Employee

The Employee states that the information supplied with this request is accurate to the best of the Employee's knowledge. Fraudulently obtained leave is not protected by the Act. See 29 C.F.R. § 825.216(d).

V. ONGOING RESPONSIBILITIES

5.1 Employee Covenants

(a) Periodic Status Reports: Employee shall respond to nondiscriminatory Employer requests for status and intent-to-return reports at reasonable intervals.

(b) Changed Circumstances: When foreseeable, Employee shall provide reasonable notice—ordinarily within two (2) business days—if the anticipated leave duration changes.

(c) Outside Employment: A uniformly applied Employer policy governing outside or supplemental employment continues during FMLA Leave. In the absence of such a policy, outside work alone is not a basis to deny FMLA rights unless leave was fraudulently obtained.

(d) Employee Premium Share: Employee shall pay the employee share of group-health premiums under the advance written payment terms supplied by Employer.

5.2 Employer Covenants

(a) Non-Interference & Non-Retaliation: Employer shall not interfere with, restrain, or deny exercise of FMLA rights nor retaliate for their exercise.

(b) Records & Confidentiality: Employer shall retain required FMLA records for at least three years. Certifications, recertifications, and medical histories shall be kept as confidential medical records separate from usual personnel files. See 29 C.F.R. § 825.500.

VI. CERTIFICATION, BENEFITS, AND REMEDIES

6.1 Certification Consequences

The Employer may delay or deny FMLA protection for a failure to provide a requested complete and sufficient Certification only after providing the notices, opportunity to cure, and consequences required by 29 C.F.R. § 825.305 and related regulations.

6.2 Late Health-Plan Premiums

In the absence of a longer Employer grace period, coverage may cease when the Employee's premium payment is more than thirty (30) days late only if Employer mails written notice at least fifteen (15) days before the stated coverage-termination date. Other FMLA obligations continue, and equivalent coverage must be restored upon return. See 29 C.F.R. § 825.212.

6.3 Recovery of Employer-Paid Premiums

For unpaid FMLA Leave, Employer may recover its share of group-health premiums only if Employee fails to return after FMLA entitlement is exhausted or expires and the failure is not caused by a qualifying serious health condition or other circumstances beyond Employee's control. See 29 U.S.C. § 2614(c)(2) and 29 C.F.R. § 825.213.

6.4 Employee Remedies

An eligible employee affected by a violation retains the remedies provided by 29 U.S.C. § 2617, including specified lost compensation or actual monetary loss, interest, potential liquidated damages, and appropriate equitable relief such as employment, reinstatement, or promotion.

6.5 Attorneys’ Fees & Costs

In an employee action under 29 U.S.C. § 2617, the court shall add reasonable attorney fees, expert-witness fees, and costs to a judgment awarded to the plaintiff. This worksheet does not create a reciprocal prevailing-party fee right for Employer.

VII. PRESERVATION OF RIGHTS

7.1 No Prospective Waiver

Employee cannot waive, and Employer cannot induce Employee to waive, prospective FMLA rights. This worksheet contains no indemnity, liability cap, release, or force-majeure term limiting duties or remedies under the Act. See 29 C.F.R. § 825.220(d).

7.2 Other Protections

The Act does not supersede a state or local law, collective-bargaining agreement, or employer policy that provides greater family or medical leave rights. Review all applicable protections separately.

VIII. ENFORCEMENT INFORMATION

8.1 Governing Requirements

Federal FMLA rights are governed by the Act and 29 C.F.R. Part 825. More protective state, local, contractual, or employer-policy rights may also apply.

8.2 Forum

An employee action under 29 U.S.C. § 2617 may be maintained in any federal or state court of competent jurisdiction. This worksheet selects no exclusive forum.

8.3 Other Dispute Agreements

This worksheet creates no arbitration agreement and does not amend any otherwise valid dispute-resolution agreement. Counsel should separately review enforceability and scope.

8.4 No Jury Waiver

This worksheet contains no jury-trial waiver.

8.5 Equitable Relief

Nothing in this worksheet limits equitable relief available under 29 U.S.C. § 2617.

IX. GENERAL PROVISIONS

9.1 Corrections and Updates

Employer may update administrative entries as additional information is received, but no entry may waive or reduce a right supplied by law.

9.2 State and Local Addendum

Attach any state, local, collective-bargaining, or employer-policy notice that provides additional or greater rights.

9.3 Severability

If any provision of this worksheet is invalid or unenforceable, the remaining administrative entries remain usable to the extent permitted by law.

9.4 No Entire-Agreement Effect

This worksheet supplements, and does not replace, required FMLA notices, Certifications, applicable policies, or rights arising under other law.

9.5 Counterparts; Electronic Signatures

This worksheet may be signed in counterparts and transmitted electronically.

X. RECEIPT BLOCK

The signatures below acknowledge submission and receipt only. They do not determine eligibility, designate leave, or waive any right. An Employee signature is not a condition to notice of a potentially FMLA-qualifying need for leave.

EXHIBIT A

EMPLOYEE LEAVE ELECTION SCHEDULE

EXHIBIT B

OPTIONAL-USE DOL FMLA FORMS

1. WH-381 – Notice of Eligibility and Rights & Responsibilities (Employer-Prepared)
2. WH-382 – Designation Notice (Employer-Prepared)
3. [Select One or More Employee-Provided Forms:]

• WH-380-E – Employee’s Serious Health Condition
• WH-380-F – Family Member’s Serious Health Condition
• WH-384 – Qualifying Exigency
• WH-385 – Service-Member Caregiver (Current)
• WH-385-V – Service-Member Caregiver (Veteran)

Employers may use the current DOL forms or equivalent forms that request no more information than the regulations permit. Completed Certifications are returned to the Employer, not to the U.S. Department of Labor.

SOURCES AND REFERENCES

• U.S. Department of Labor — FMLA Forms
• 29 C.F.R. Part 825 — Family and Medical Leave Act Regulations
• 29 U.S.C. Chapter 28 — Family and Medical Leave

EXHIBIT C

CALIFORNIA STATE LAW ADDENDUM (CFRA / PDL / PFL)

1. CFRA Coordination

• An employee of an employer with five or more employees may be eligible under the California Family Rights Act (Gov. Code § 12945.2) for up to twelve workweeks of job-protected leave in a twelve-month period for bonding, qualifying family care, the employee's own serious health condition, or a covered military exigency.
• CFRA eligibility generally requires more than twelve months of service and at least 1,250 hours worked in the preceding twelve months. The federal fifty-employees-within-seventy-five-miles test does not apply to CFRA.

2. Pregnancy Disability Leave (PDL)

• If pregnancy, childbirth, or a related medical condition causes disability, an employee may be entitled to up to four months of Pregnancy Disability Leave, depending on the period of actual disability. See Gov. Code § 12945.
• An employee who is also eligible for CFRA may take CFRA leave related to the birth of the child in addition to Pregnancy Disability Leave.

3. Paid Family Leave / SDI

• California Paid Family Leave provides short-term wage-replacement benefits for bonding, care of a seriously ill family member, or support connected with a family member's military deployment. The EDD program provides benefit payments but not job protection.
• Direct the Employee to the EDD claim process and separately determine job protection under CFRA, FMLA, Pregnancy Disability Leave, or another applicable law.

4. State Notices and Forms

• Provide required California notices and any permitted certification request applicable to the leave reason.
• Attach the California notices or record their delivery date: [DATE].

California Sources

• California Civil Rights Department — Family Care, Medical Leave, and Pregnancy Disability Leave
• California Civil Rights Department — Expanded Family and Medical Leave
• California EDD — Paid Family Leave