FMLA Leave Request Form

FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Hawaii

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: Hawaii Family Leave Law (HRS Chapter 398); Hawaii TDI (HRS Chapter 392)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Hawaii-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. Hawaii-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 — 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 family member with a serious health condition (29 U.S.C. § 2612(a)(1)(C); HRS § 398-3)

• 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); HRS § 398-3)

☐ Adoption — For the adoption of a child (29 U.S.C. § 2612(a)(1)(B); HRS § 398-3)

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

☐ 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 (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. HAWAII-SPECIFIC LEAVE PROVISIONS

5A. Hawaii Family Leave Law (HRS Chapter 398)

Employer Coverage: Employers with 100 or more employees for each working day during each of 20 or more calendar weeks in the current or preceding calendar year.

Employee Eligibility: Must have worked for the employer for at least 6 consecutive months.

Leave Entitlement: Up to 4 weeks of family leave per calendar year.

Qualifying Reasons Under HFLL:

• Birth of a child
• Adoption of a child
• Care for a child, spouse, reciprocal beneficiary, sibling, grandchild, grandparent, or parent with a serious health condition

Expanded Family Member Definition (HFLL):
Hawaii's definition is broader than federal FMLA and includes:

• Spouse or reciprocal beneficiary
• Parent, parent-in-law, step-parent
• Child (minor or adult), step-child
• Sibling
• Grandparent, grandchild

Paid vs. Unpaid: HFLL leave may be paid or unpaid. Employers that provide sick leave must permit employees to use their own accrued sick leave for family leave purposes (HRS § 398-4).

☐ Employer has 100+ employees and is covered by the HFLL.
☐ Employer has fewer than 100 employees (HFLL does not apply).

5B. Hawaii Temporary Disability Insurance (HRS Chapter 392)

Coverage: Virtually all Hawaii employers with one or more employees must provide TDI.

Benefit: Partial wage replacement for up to 26 weeks for a non-work-related illness, injury, or pregnancy-related disability.

Maximum Weekly Benefit (2026): Verify current maximum at labor.hawaii.gov.

Coordination with FMLA: TDI benefits may be received concurrently with FMLA leave when the employee is disabled by their own serious health condition.

☐ Employee is applying for Hawaii TDI concurrently with FMLA leave.
☐ TDI does not apply to this leave request.

5C. No State Paid Family Leave Program

As of 2026, Hawaii does not operate a state-funded paid family leave insurance program. Bills have been introduced but none enacted as of this date.

6. LEAVE SCHEDULE AND DATES

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

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

HFLL Leave Used / Remaining (calendar year): [____] / [____] 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
• ☐ Hawaii TDI claim form (for employee's own disability)

9. JOB RESTORATION RIGHTS

• Federal FMLA: Restoration to the same or equivalent position (29 U.S.C. § 2614(a)).
• HFLL: Employee is entitled to restoration to the same or a comparable position upon return (HRS § 398-7).

☐ 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)).
• HFLL: Employer must maintain all benefits during the leave period (HRS § 398-7).
• Employee must continue to pay their share of premiums.

11. HAWAII-SPECIFIC NOTES

• Concurrent Leave: Federal FMLA and HFLL run concurrently when both apply.
• HFLL Provides Less Leave: HFLL provides 4 weeks vs. FMLA's 12 weeks, but HFLL covers reciprocal beneficiaries, siblings, and grandchildren/grandparents.
• HFLL Does Not Cover Own Health Condition: Only federal FMLA covers the employee's own serious health condition; HFLL covers family care only.
• Hawaii TDI: Provides wage replacement for the employee's own disability including pregnancy/childbirth, which may be coordinated with FMLA.
• Reciprocal Beneficiary: Hawaii recognizes reciprocal beneficiary relationships for purposes of HFLL family care leave.

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, the Hawaii Family Leave Law, and Hawaii TDI (if applicable).
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: [__/__/____]
• ☐ HFLL Notice (if applicable) — Date: [__/__/____]

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

Sources and References:

• U.S. Department of Labor — FMLA
• HRS Chapter 398 — Hawaii Family Leave Law
• HRS Chapter 392 — Hawaii TDI
• Hawaii Dept. of Labor — Family Leave