FMLA Leave Request Form - District of Columbia

FAMILY AND MEDICAL LEAVE REQUEST FORM

District of Columbia

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
DC Authority: DC FMLA (D.C. Code §§ 32-501–32-517); Universal Paid Leave Act (D.C. Code §§ 32-541.01–32-541.17)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. DC-Specific Leave Provisions
6. Leave Schedule and Dates
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. DC-Specific Notes
12. Employee Acknowledgment and Signature
13. Employer Response

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. TYPE OF LEAVE REQUESTED

Please indicate the reason for your leave request:

☐ Own Serious Health Condition (Medical Leave) — A serious health condition rendering the employee unable to perform essential job functions (29 U.S.C. § 2612(a)(1)(D); D.C. Code § 32-502)

☐ Family Member Care (Family Leave) — To care for a family member with a serious health condition (29 U.S.C. § 2612(a)(1)(C); D.C. Code § 32-502)

• Relationship to employee: [________________________________]
• Name of family member: [________________________________]

☐ Birth and Bonding (Parental Leave) — For the birth of a child and to bond with the newborn (29 U.S.C. § 2612(a)(1)(A); D.C. Code § 32-502)

☐ Adoption or Foster Care Placement (Parental Leave) — For placement of a child for adoption or foster care (29 U.S.C. § 2612(a)(1)(B); D.C. Code § 32-502)

☐ Qualifying Exigency — Related to a family member's military service (29 U.S.C. § 2612(a)(1)(E))

• Type of exigency: [________________________________]

☐ Military Caregiver Leave — To care for a covered servicemember with a serious injury or illness (29 U.S.C. § 2612(a)(3))

• Relationship to servicemember: [________________________________]

☐ Prenatal Care (DC UPL Only) — For prenatal medical care appointments and pregnancy-related complications (D.C. Code § 32-541.01)

4. FEDERAL FMLA OVERVIEW

• Eligibility: 12 months of employment, 1,250 hours in prior 12 months, worksite with 50+ employees within 75 miles (29 C.F.R. § 825.110).
• Leave Entitlement: Up to 12 workweeks of unpaid, job-protected leave per 12-month period.
• Military Caregiver Leave: Up to 26 workweeks in a single 12-month period.
• Notice: 30 days' advance notice when foreseeable; as soon as practicable otherwise.

5. DC-SPECIFIC LEAVE PROVISIONS

5A. DC Family and Medical Leave Act (D.C. Code §§ 32-501 to 32-517)

Employer Coverage: Current D.C. Code § 32-501 defines a covered employer without a twenty-Employee threshold. Confirm that the employer and Employee fall within the statutory definitions and exclusions.

Employee Eligibility: Worked for the same employer for at least 12 consecutive or nonconsecutive months within the preceding 7 years and at least 1,000 hours during the 12 months preceding leave.

Leave Entitlement:

• Family Leave: Up to 16 workweeks of unpaid leave during any 24-month period for the birth, adoption, or foster placement of a child, or to care for a family member with a serious health condition.
• Medical Leave: Up to 16 workweeks of unpaid leave during any 24-month period for the employee's own serious health condition.

DC FMLA Family Member Definition:

• Spouse (including same-sex spouse)
• Child (biological, adopted, foster, step, legal ward) living with the employee and under 21 or financially dependent
• Parent, parent-in-law
• Person with whom the employee shares or has shared a mutual residence and maintained a committed relationship within the preceding 12 months

5B. DC Universal Paid Leave (D.C. Code §§ 32-541.01 to 32-541.17)

Eligibility: Employee must work for a DC-covered employer and have earned wages in DC. There is no minimum tenure or hours requirement.

Benefit Duration (2026):
| Leave Type | Maximum Duration |
|-----------|-----------------|
| Parental Leave (birth, adoption, foster) | 12 weeks per year |
| Family Leave (care for ill family member) | 12 weeks per year |
| Medical Leave (own serious health condition) | 12 weeks per year |
| Prenatal Leave (prenatal care/complications) | 2 weeks per year |
| Combined Maximum | 12 weeks total (plus 2 weeks prenatal) |

Wage Replacement:

• 90% of average weekly wages up to 150% of DC minimum wage x 40 hours.
• 50% of average weekly wages above that threshold.
• Maximum Weekly Benefit: Adjusted annually with CPI (verify current maximum at does.dc.gov).

Program Funding: Employer payroll contributions fund the program. Confirm the current contribution rate with the D.C. Department of Employment Services before calculating or stating an amount.

☐ Employee is requesting DC UPL paid benefits.
☐ Employee is requesting DC FMLA job-protected leave.
☐ Employee is requesting federal FMLA leave.
☐ Employee is requesting all applicable leave protections.

DC UPL Claim Number (if filed): [________________________________]

6. LEAVE SCHEDULE AND DATES

Employer's 12-Month Leave Period Method (Federal FMLA): [________________________________]

Federal FMLA Leave Used / Remaining: [____] / [____] weeks

DC FMLA Leave Used / Remaining (24-month period): [____] / [____] weeks

DC UPL Leave Used / Remaining: [____] / [____] weeks

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
• ☐ WH-385 — Serious Injury or Illness of a Current Servicemember
• ☐ WH-385-V — Serious Injury or Illness of a Veteran
• ☐ DC DOES UPL certification form

9. JOB RESTORATION RIGHTS

• Federal FMLA: Restoration to the same or equivalent position (29 U.S.C. § 2614(a)).
• DC FMLA: Restoration to the same or equivalent position (D.C. Code § 32-505).
• DC UPL Anti-Retaliation: Employers may not retaliate against employees for filing or requesting UPL benefits (D.C. Code § 32-541.08).

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

10. BENEFITS CONTINUATION

• Federal FMLA: Employer must maintain group health insurance during leave (29 U.S.C. § 2614(c)).
• DC FMLA: Employer must maintain all employment benefits during the leave period (D.C. Code § 32-505(d)).
• Employee must continue to pay their share of premiums.

11. DC-SPECIFIC NOTES

• Concurrent Leave: Federal FMLA, DC FMLA, and DC UPL may run concurrently. DC UPL provides wage replacement; DC FMLA and federal FMLA provide job protection.
• DC Government Employees: DC government employees are not covered by UPL but have separate paid leave provisions under D.C. Code § 1-612.03c.
• UPL Claims: File claims through DOES at does.dc.gov/page/dc-paid-family-leave.
• Employer Size Differences:
• Federal FMLA: 50+ employees
• DC FMLA: Current § 32-501 has no 20-employee threshold; confirm statutory definitions and exclusions
• DC UPL: All private employers (no size threshold)
• DC FMLA Provides More Leave: DC FMLA provides 16 weeks per 24 months (compared to federal FMLA's 12 weeks per 12 months).

12. 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 under federal FMLA, DC FMLA, and DC Universal Paid Leave.
3. I understand that medical certification may be required.
4. I understand that misrepresentation may result in disciplinary action and/or denial of benefits.

13. EMPLOYER RESPONSE

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

Notices Provided:

• ☐ WH-381 (Eligibility/Rights & Responsibilities Notice) — Date: [__/__/____]
• ☐ WH-382 (Designation Notice) — Date: [__/__/____]
• ☐ DC FMLA Rights Notice — Date: [__/__/____]
• ☐ DC UPL Rights Notice — Date: [__/__/____]

This form does not replace DOL FMLA forms or DOES UPL claim forms. Employers must issue all required federal and DC notices.

Sources and References:

• U.S. Department of Labor — FMLA
• D.C. Code §§ 32-501–32-517 (DC FMLA)
• D.C. Code §§ 32-541.01–32-541.17 (Universal Paid Leave)
• DC Paid Family Leave — DOES
• DC Office of Human Rights — UPL Guidance