FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Delaware

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: Healthy Delaware Families Act (19 Del. C. §§ 3701–3726)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Delaware Paid Family and Medical Leave
6. Leave Schedule and Dates
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. Delaware-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); 19 Del. C. § 3703)

☐ Family Member Care (Caregiving Leave) — To care for a family member with a serious health condition (29 U.S.C. § 2612(a)(1)(C); 19 Del. C. § 3703)
- 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); 19 Del. C. § 3703)

☐ 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); 19 Del. C. § 3703)

☐ Qualifying Exigency — Related to a family member's military deployment (29 U.S.C. § 2612(a)(1)(E); 19 Del. C. § 3703)
- 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: [________________________________]

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. DELAWARE PAID FAMILY AND MEDICAL LEAVE

5A. Healthy Delaware Families Act Overview

Employer Coverage Thresholds:
| Employer Size (DE employees) | Required Benefits |
|------------------------------|------------------|
| 10–24 employees | Parental leave benefits only |
| 25+ employees | Full program (parental + medical + caregiving + military exigency) |
| Fewer than 10 employees | Not required to participate (may opt in voluntarily) |

Employee Eligibility: Must have worked for the employer for at least 12 months and earned at least $10,000 in wages in the 12 months before the leave.

5B. Delaware PFML Benefit Duration

5C. Delaware PFML Wage Replacement

• Up to 80% of average weekly wages.
• Maximum Weekly Benefit: $900/week (adjusted annually after 2027).
• Benefits are paid by the Delaware Department of Labor Paid Leave program.

5D. Delaware PFML Contributions

• Total premium rate is shared between employer and employee.
• Employers with 25+ employees: employer pays a share of premiums for all benefit categories.
• Employers with 10–24 employees: employer pays parental leave premium only.

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

Delaware Paid Leave Claim Number (if filed): [________________________________]

5E. 2025 Amendment — No Mandatory PTO Exhaustion

Under the 2025 amendment (HS 1 for HB 128), employers are prohibited from requiring employees to exhaust accrued paid time off (vacation, sick leave, PTO) before using Delaware Paid Family Leave Insurance benefits. Employees may voluntarily choose to use accrued PTO to supplement PFML benefits.

6. LEAVE SCHEDULE AND DATES

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

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

DE PFML 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
- ☐ Delaware Paid Leave certification form

9. JOB RESTORATION RIGHTS

• Federal FMLA: Restoration to the same or equivalent position (29 U.S.C. § 2614(a)).
• Delaware PFML: Job protection is provided for employees receiving Delaware PFML benefits. Employers may not retaliate against employees for requesting or taking paid leave.

☐ 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)).
• Delaware PFML: Employer must maintain employment benefits during leave.
• Employee must continue to pay their share of premiums.

11. DELAWARE-SPECIFIC NOTES

• Concurrent Leave: Federal FMLA and Delaware PFML run concurrently when both apply.
• Delaware Paid Leave Claims: File claims at labor.delaware.gov/delaware-paid-leave.
• Private Plan Option: Employers may apply for approval to use a private plan that meets or exceeds the state program.
• New Program (2026): Delaware PFML benefits are newly available as of January 1, 2026; rules and administration may evolve.
• Small Employer Exemption: Employers with fewer than 10 Delaware employees are not required to participate but may opt in.

☐ Employer participates in the state Delaware PFML program.
☐ Employer has an approved private PFML plan.

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 and the Healthy Delaware Families Act.
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: [__/__/____]
- ☐ Delaware PFML Rights Notice — Date: [__/__/____]

This form does not replace DOL FMLA forms or Delaware Paid Leave claim forms. Employers must issue all required federal and state notices.

Sources and References:
- U.S. Department of Labor — FMLA
- Delaware Department of Labor — Paid Leave
- 19 Del. C. §§ 3701–3726 (Healthy Delaware Families Act)
- Delaware Paid Leave Program Launch (2026)