FMLA Leave Request Form

comments and customize as needed
3. Remove all guidance comments before final execution
4. Have this document reviewed by qualified legal counsel

JURISDICTION: IL — Illinois
LAST UPDATED: 2026-04-04
-->

FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Illinois

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: Various Illinois leave statutes (see Section 5 below)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Illinois-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. Illinois-Specific Notes
12. Employee Acknowledgment and Signature
13. Employer Response

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. TYPE OF LEAVE REQUESTED

Federal FMLA Leave:

☐ 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 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: [________________________________]

Concurrent Illinois Leave (if applicable):

☐ VESSA Leave — Victims' Economic Security and Safety Act (820 ILCS 116/)
☐ Family Bereavement Leave — (820 ILCS 154/)
☐ Child Extended Bereavement Leave — (820 ILCS 156/)
☐ NICU Leave — Neonatal intensive care leave (effective June 1, 2026)

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. ILLINOIS-SPECIFIC LEAVE PROVISIONS

5A. Paid Leave for All Workers Act (820 ILCS 180/)

Effective: January 1, 2024.

Coverage: Nearly all Illinois employers and employees (with limited exceptions for certain categories).

Entitlement: Employees accrue 1 hour of paid leave for every 40 hours worked, up to 40 hours of paid leave per 12-month period.

Use: This leave may be used for any reason, including during FMLA leave. The employee is not required to provide a reason for using this leave.

☐ Employee elects to use accrued Paid Leave for All Workers Act leave during FMLA leave.

5B. Employee Sick Leave Act (820 ILCS 105/4.1)

Employers that provide personal sick leave benefits must allow employees to use such leave for absences due to illness, injury, or medical appointments of the employee's child, stepchild, spouse, sibling, parent, mother-in-law, father-in-law, grandchild, grandparent, or stepparent on the same terms as the employee's own illness.

☐ Employee elects to use employer-provided sick leave for family care under this Act.

5C. Victims' Economic Security and Safety Act (VESSA) (820 ILCS 116/)

Coverage: Employers with 1+ employees.

Entitlement: Up to 12 weeks of unpaid leave per 12-month period for employees who are victims of domestic violence, sexual violence, or gender violence (or whose family/household members are victims).

Qualifying Reasons: Seeking medical attention, obtaining victim services, counseling, safety planning, legal assistance, or relocation.

Coordination with FMLA: VESSA leave may run concurrently with FMLA leave if the qualifying reason overlaps.

☐ Employee is also requesting VESSA leave.

5D. Family Bereavement Leave Act (820 ILCS 154/)

Coverage: Employers with 50+ employees within a 75-mile radius.

Entitlement: Up to 10 work days of unpaid leave for the death of a covered family member, or for a miscarriage, unsuccessful reproductive procedure, failed adoption, or other qualifying event.

Coordination: Leave taken under FBLA counts against FMLA entitlement if the employee is FMLA-eligible.

5E. Child Extended Bereavement Leave Act (820 ILCS 156/)

Effective: January 1, 2024.

Coverage: Employers with 50+ full-time employees in Illinois.

Entitlement: Up to 12 weeks of unpaid leave for employees who have lost a child to suicide or homicide.

5F. NICU Leave (Effective June 1, 2026)

Coverage:

• Employers with 16–50 employees: Up to 10 days of unpaid NICU leave.
• Employers with 51+ employees: Up to 20 days of unpaid NICU leave.

Qualifying Reason: Employee has a child receiving inpatient care in a neonatal intensive care unit.

☐ Employee is also requesting NICU leave (effective June 1, 2026).

5G. No State Paid Family and Medical Leave Insurance Program

As of 2026, Illinois does not operate a state-funded PFML insurance program. Legislation has been introduced (HB 3483 / SB 2413, 104th General Assembly) but not enacted.

6. LEAVE SCHEDULE AND DATES

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

Federal FMLA 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
• ☐ VESSA certification (if applicable)

9. JOB RESTORATION RIGHTS

• Federal FMLA: Restoration to the same or equivalent position (29 U.S.C. § 2614(a)).
• VESSA: Restoration to the same or equivalent position after VESSA leave (820 ILCS 116/20).
• Anti-Retaliation: Illinois law prohibits retaliation for exercising rights under VESSA, FBLA, Child Extended Bereavement, or the Paid Leave for All Workers Act.

☐ 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)).
• 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. ILLINOIS-SPECIFIC NOTES

• Multiple Concurrent Leaves: Illinois employees may have overlapping entitlements under federal FMLA, VESSA, FBLA, and other state statutes. Leave that qualifies under multiple laws typically runs concurrently.
• Paid Leave for All Workers Act: Provides 40 hours of paid leave per year for any reason — may be used to partially replace lost income during FMLA leave.
• No PFML Program (Yet): Unlike neighboring states, Illinois does not have a state paid family leave insurance program as of 2026.
• Chicago/Cook County Ordinances: The City of Chicago and Cook County may have additional leave requirements. Verify local ordinances for employees working in those jurisdictions.
• VESSA Protections: VESSA applies to all Illinois employers with 1+ employees — broader than federal FMLA's 50-employee threshold.

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 applicable Illinois leave laws.
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: [__/__/____]
• ☐ VESSA Rights Notice (if applicable) — Date: [__/__/____]

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

Sources and References:

• U.S. Department of Labor — FMLA
• 820 ILCS 180/ — Paid Leave for All Workers Act
• 820 ILCS 105/4.1 — Employee Sick Leave Act
• 820 ILCS 116/ — VESSA
• 820 ILCS 154/ — Family Bereavement Leave Act
• 820 ILCS 156/ — Child Extended Bereavement Leave Act
• Illinois Department of Labor — Leave Rights