FMLA Leave Request Form - Georgia

FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Georgia

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: Georgia Family Care Act (O.C.G.A. § 34-1-10)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Georgia-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 rendering 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 (29 U.S.C. § 2612(a)(1)(A))

☐ Adoption or Foster Care Placement — For placement of a child for adoption or foster care (29 U.S.C. § 2612(a)(1)(B))

☐ Qualifying Exigency — Related to 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 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. GEORGIA-SPECIFIC PROVISIONS

5A. Georgia Family Care Act (O.C.G.A. § 34-1-10)

Employer Coverage: Employers with 25 or more employees that voluntarily provide paid sick leave.

Employee Right: An eligible employee may use up to 5 days of accrued employer-provided sick leave per calendar year to care for an immediate family member (including spouse, grandchild, grandparent, parent, or child).

Key Limitation: This does not require employers to provide sick leave — it only requires that employers who already provide sick leave allow employees to use a portion for family care.

☐ Employer provides paid sick leave and is subject to the Georgia Family Care Act.
☐ Employer does not provide paid sick leave / has fewer than 25 employees.

☐ Employee elects to use accrued employer-provided sick leave during FMLA leave under the Family Care Act.

5B. Georgia State Employee Paid Parental Leave (HB 1010 — 2024)

Effective July 1, 2024, Georgia state employees are eligible for up to 240 hours (approximately 6 weeks) of paid parental leave following the birth, adoption, or foster placement of a child.

☐ I am a Georgia state employee eligible for paid parental leave under HB 1010.
☐ I am a private-sector employee; only federal FMLA applies.

5C. No State Paid Family Leave Program

Georgia does not operate a state-funded paid family and medical leave (PFML) insurance program for private-sector workers. FMLA leave in Georgia is unpaid unless the employee substitutes accrued paid leave or the employer provides supplemental pay.

5D. Substitution of Accrued Paid Leave

☐ Employee elects to substitute accrued paid leave (vacation, sick, PTO) during FMLA leave.
☐ Employee does not elect to substitute accrued paid leave at this time.
☐ Employer requires substitution of accrued paid leave per company policy.

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
• ☐ 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 (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 Georgia 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
• O.C.G.A. § 34-1-10 (Georgia Family Care Act)
• Georgia Department of Administrative Services — Family Medical Leave