FMLA Leave Request Form

FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Idaho

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Notes: Idaho has no private-sector state FMLA supplement; federal FMLA governs

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Idaho-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: Employee must have worked for the employer for at least 12 months, with at least 1,250 hours of service during the preceding 12 months, at a 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 (29 U.S.C. § 2612(a)(3)).
• Notice Requirement: At least 30 days' advance notice when foreseeable; as soon as practicable when not foreseeable (29 C.F.R. §§ 825.302–303).

5. IDAHO-SPECIFIC PROVISIONS

5A. No State FMLA Supplement for Private Employers

Idaho has not enacted a state family and medical leave law. Private-sector employees in Idaho have only the rights guaranteed by the federal FMLA. There is no state-mandated paid or unpaid family leave beyond federal requirements.

5B. Idaho State Employee Paid Parental Leave (Family First Act)

In January 2020, Governor Brad Little signed Executive Order 2020-01 establishing 8 weeks of paid parental leave for eligible executive branch state employees following the birth or adoption of a child. This benefit does not apply to private-sector workers.

☐ I am an Idaho state executive branch employee eligible for paid parental leave.
☐ I am a private-sector employee; only federal FMLA applies.

5C. No State Paid Sick Leave Mandate

Idaho does not require private employers to provide paid sick leave. However, employees may substitute accrued employer-provided paid leave (vacation, sick, PTO) for unpaid FMLA leave under 29 C.F.R. § 825.207.

☐ Employee elects to substitute accrued paid leave 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.

5D. No State Paid Family Leave Program

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

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.
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
• Idaho State Controller — FMLA
• Idaho Executive Order 2020-01 (Family First)