FMLA LEAVE REQUEST FORM — INDIANA

Table of Contents

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Leave Schedule and Dates
6. Intermittent or Reduced Schedule Leave
7. Medical Certification
8. Indiana-Specific Considerations
9. Job Restoration Rights
10. Benefits During Leave
11. Employee Certification and Signature
12. Employer Response
13. Sources and References

1. Employee Information

2. Employer Information

3. Type of Leave Requested

Please check the applicable reason for leave:

☐ Serious Health Condition (Employee) — Employee's own serious health condition that renders the employee unable to perform the essential functions of the position.

☐ Serious Health Condition (Family Member) — To care for a spouse, child, or parent with a serious health condition.

☐ Birth of Child / Bonding — For the birth of a son or daughter and to bond with the newborn child within 12 months of birth.

☐ Adoption or Foster Care Placement — For the placement of a child for adoption or foster care and to bond with the newly placed child within 12 months of placement.

☐ Qualifying Exigency (Military) — For any qualifying exigency arising out of the fact that the employee's spouse, son, daughter, or parent is a covered military member on active duty or has been notified of an impending call or order to active duty.

☐ Military Caregiver Leave — To care for a covered servicemember with a serious injury or illness (up to 26 weeks in a single 12-month period).

4. Federal FMLA Overview

Under the federal Family and Medical Leave Act (29 U.S.C. § 2601 et seq.):

• Eligible employees may take up to 12 workweeks of unpaid, job-protected leave in a 12-month period (or 26 weeks for military caregiver leave).
• Employer coverage: Private employers with 50 or more employees in 20 or more workweeks in the current or preceding calendar year.
• Employee eligibility: Must have worked for the employer for at least 12 months, have at least 1,250 hours of service in the 12 months preceding the leave, and work at a location where the employer has at least 50 employees within 75 miles.
• Leave is unpaid, but employees may elect or the employer may require the substitution of accrued paid leave.

5. Leave Schedule and Dates

If foreseeable, employee must provide at least 30 days' advance notice. If not foreseeable, notice must be given as soon as practicable (generally the same or next business day).

6. Intermittent or Reduced Schedule Leave

☐ I am requesting intermittent leave (leave taken in separate blocks of time).
☐ I am requesting a reduced work schedule (reducing the usual number of hours per workweek or workday).

If applicable, provide details:

7. Medical Certification

☐ Medical certification is attached.
☐ Medical certification will be provided by: [__/__/____]

Certifying Health Care Provider:

8. Indiana-Specific Considerations

No State FMLA Supplement. Indiana has not enacted a state-level family or medical leave law that expands upon federal FMLA protections for private-sector employees. Employees in Indiana rely exclusively on the federal FMLA and any employer-provided leave policies.

No State Paid Family Leave Program. Indiana does not operate a state-funded paid family or medical leave insurance program. No payroll contributions are collected for state paid leave benefits.

Indiana Military Family Leave. Under Ind. Code § 22-2-14, employers with 50 or more employees must provide up to 10 days of unpaid leave per year to the spouse, parent, grandparent, or sibling of a person called to active duty in the U.S. armed forces.

State Employee Programs. Indiana state government employees may have access to a paid New Parent Leave benefit for birth, adoption, or foster care placement, administered through the State Personnel Department. This benefit does not extend to private-sector employees.

Workers' Compensation. If the serious health condition resulted from a workplace injury, the employee may have concurrent rights under Indiana's Workers' Compensation Act (Ind. Code § 22-3).

Additional Employer Policies. Employees should review their employer's handbook or leave policy for any supplemental paid or unpaid leave benefits beyond federal FMLA:

☐ Employer offers supplemental paid leave: [________________________________]
☐ Employer does not offer supplemental paid leave beyond FMLA.

9. Job Restoration Rights

Under federal FMLA, eligible employees are entitled to:

• Be restored to the same position or an equivalent position with equivalent pay, benefits, and other terms and conditions of employment upon return from FMLA leave.
• Continued group health insurance coverage during leave on the same terms as if the employee had continued to work.

☐ Employee has been identified as a key employee under 29 C.F.R. § 825.218.

10. Benefits During Leave

Type and amount of accrued paid leave available:

11. Employee Certification and Signature

I certify that the information provided in this request is true and complete to the best of my knowledge. I understand that:

• FMLA leave is unpaid unless I elect or am required to substitute accrued paid leave.
• I must provide medical certification if requested by my employer.
• Failure to return from FMLA leave may result in the obligation to reimburse employer-paid health insurance premiums during the leave period.
• Misrepresentation of facts to obtain FMLA leave may result in disciplinary action, up to and including termination.

Employee Signature: [________________________________]
Date: [__/__/____]

12. Employer Response

HR Representative Signature: [________________________________]
Title: [________________________________]
Date: [__/__/____]

13. Sources and References

• U.S. Department of Labor — FMLA Fact Sheet #28
• 29 U.S.C. § 2601 et seq. — Family and Medical Leave Act
• 29 C.F.R. Part 825 — FMLA Regulations
• Ind. Code § 22-2-14 — Military Family Leave
• Indiana State Personnel Department — Family & Medical Leave
• NOLO — Family and Medical Leave in Indiana

This document is a template only and does not constitute legal advice. Legal review is strongly recommended before implementation. Indiana employers should ensure compliance with all applicable federal and state employment laws.