FMLA Leave Request Form - Iowa
FMLA Leave Request Form — Iowa
To: [EMPLOYER / HR CONTACT]
From: [EMPLOYEE NAME]
Date submitted: [__/__/____]
I request review of leave under the federal Family and Medical Leave Act for the reason and schedule stated below. Please contact me about any information or certification needed to process the request. I also ask that you consider any other applicable leave, accommodation, or employer policy identified below.
1. Employee and contact information
| Field | Response |
|---|---|
| Employee name | [________________________________] |
| Employee ID, if used | [________________________________] |
| Job title and work location | [________________________________] |
| Supervisor | [________________________________] |
| Preferred phone | [________________________________] |
| Preferred email or mailing address | [________________________________] |
| Best way and time to contact me during leave | [________________________________] |
2. Reason for leave
Check each reason that applies. Include only the information needed to identify the leave category; provide medical details through the employer's separate confidential certification process.
☐ My own serious health condition affects my ability to work.
☐ I need to care for my spouse, child, or parent with a serious health condition. Relationship: [________________].
☐ Birth of my child and care or bonding following birth. Expected or actual date: [__/__/____].
☐ Placement of a child with me for adoption or foster care. Expected or actual date: [__/__/____].
☐ Qualifying exigency related to my spouse, child, or parent's covered military duty. Relationship and general reason: [________________________________].
☐ Care for a covered servicemember with a serious injury or illness. My relationship to the servicemember: [________________________________].
☐ I am unsure which category applies. General description without diagnosis: [________________________________].
Iowa pregnancy-related disability review: ☐ This request concerns disability caused or contributed to by pregnancy, childbirth, or a related medical condition. Please also review any leave available under Iowa Code § 216.6(2), if applicable.
Other leave or accommodation requested for review: [EMPLOYER POLICY / PAID LEAVE / DISABILITY ACCOMMODATION / OTHER, OR "NONE"].
3. Requested schedule
| Field | Response |
|---|---|
| First day leave is needed | [__/__/____] |
| Expected last day of leave, if known | [__/__/____] |
| Expected return date, if known | [__/__/____] |
| Date I first learned leave might be needed | [__/__/____] |
| Date and method of any earlier notice to employer | [________________________________] |
| Schedule | ☐ Continuous ☐ Intermittent ☐ Reduced schedule ☐ Not yet known |
| If intermittent, expected frequency and duration | [________________________________] |
| If reduced schedule, requested workdays or hours | [________________________________] |
| Dates and schedule remain uncertain because | [________________________________] |
I will update [HR CONTACT] if the expected schedule changes. My current estimate is based on information available as of [__/__/____].
4. Certification and communications
☐ I have received an employer certification form and will return it through the designated process.
☐ Please provide the certification form or identify the information you need.
☐ I have already provided supporting information to [HR CONTACT] on [__/__/____].
Preferred confidential channel for medical or other supporting information: [________________________________].
Questions or additional information for HR: [________________________________].
5. Employee signature
I certify that the factual information I provided in this request is accurate to the best of my knowledge. I understand that the employer will review the request and communicate its decision and any required next steps separately.
Employee signature: [________________________________]
Date: [__/__/____]
Employer receipt
Received by: [________________________________]
Date and time received: [________________________________]
Contact for next steps: [________________________________]
Sources and References
About this template
- Last updated
- October 17, 2026
- Citations checked
- October 17, 2026
- Jurisdiction
- Iowa
- Category
- Employment & HR
Legal authority
- 29 U.S.C. § 2612(a)(1)
- 29 U.S.C. § 2612(a)(3)
- Iowa Code § 216.6(2)(e)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 17, 2026.
29 U.S.C. § 2612(a)(1) (checked October 17, 2026): "Subject to section 2613 of this title and subsection (d)(3), an eligible employee shall be entitled to a total of 12 workweeks of leave during any 12-month period for one or more of the following:"
29 U.S.C. § 2612(a)(3) (checked October 17, 2026): "Subject to section 2613 of this title, an eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered servicemember shall be entitled to a total of 26 workweeks of leave during a 12-month period to care for the servicemember."
Iowa Code § 216.6(2)(e) (checked October 17, 2026): "Where a leave is not available or a sufficient leave is not available under any health or temporary disability insurance or sick leave plan available in connection with employment, the employer of the pregnant employee shall not refuse to grant to the employee who is disabled by the pregnancy a leave of absence if the leave of absence is for the period that the employee is disabled because of the employee’s pregnancy, childbirth, or related medical conditions, or for eight weeks, whichever is less."
29 C.F.R. § 825.217(a) (checked October 17, 2026): "A key employee is a salaried FMLA-eligible employee who is among the highest paid 10 percent of all the employees employed by the employer within 75 miles of the employee's worksite."
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