FMLA Leave Request Form - Kansas

FMLA LEAVE REQUEST FORM — KANSAS

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. Kansas-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; public agencies and elementary and secondary schools have separate coverage rules.
• 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

Notice: Give notice as soon as practicable. For foreseeable birth, placement, or planned medical treatment, 29 U.S.C. § 2612(e) generally calls for at least 30 days' notice, with shorter notice when the event or treatment requires an earlier start. Foreseeable qualifying-exigency leave calls for notice that is reasonable and practicable.

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. Kansas-Specific Considerations

No State FMLA Supplement. Kansas has not enacted a general state-level family or medical leave law that expands federal FMLA protections for private-sector employees. Other protections, including disability and pregnancy protections discussed below, may also apply.

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

No State Mandatory Paid Sick Leave. Kansas does not require private-sector employers to provide paid sick leave. The Kansas Legislature declined to advance SB 216 (paid sick time) during the 2025 legislative session.

Kansas State Employee Paid Parental Leave (Executive Order 21-24)

Kansas Executive Order 21-24 provides paid parental leave to benefits-eligible employees in executive branch agencies and entities under the Governor's jurisdiction:

• Duration: Eight (8) weeks for a primary caregiver or four (4) weeks for a secondary caregiver, at 100% of regular pay.
• Eligibility: Benefits-eligible employees in covered agencies, whether classified or unclassified and full-time or part-time. Employees hired or rehired after the order took effect must first complete 180 days of state employment.
• Qualifying events: Birth, adoption, or foster care placement of a child.
• Limitation: The order applies to employees under the Governor's jurisdiction, not to private-sector employees or automatically to every state entity.

Kansas Act Against Discrimination (K.S.A. § 44-1001 et seq.)

Kansas law prohibits employment discrimination based on disability. Employees with qualifying disabilities may be entitled to reasonable accommodations, including leave, under the Kansas Act Against Discrimination and the federal ADA.

• Employer threshold: Applies to employers with four (4) or more employees.
• Pregnancy protections: Kansas law treats pregnancy-related conditions as temporary disabilities; employers must treat them the same as other temporary disabilities.

Additional Employer Policies. Employees should review their employer's handbook or leave policy for supplemental leave benefits:

☐ 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 leave.
• Continued group health insurance coverage during leave on the same terms as if the employee had continued to work.

☐ Employee meets the key employee definition in 29 C.F.R. § 825.217: salaried, FMLA eligible, and among the highest paid 10% of the employer's employees within 75 miles of the worksite. A key-employee designation alone does not deny restoration; the employer must evaluate whether restoration would cause substantial and grievous economic injury under § 825.218(a).

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.
• Employer-paid group-health premiums may be recoverable after a failure to return only when 29 U.S.C. § 2614(c)(2)'s conditions are met; serious-health-condition and circumstances-beyond-control exceptions apply.
• 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
• Kansas Executive Order 21-24
• Kansas Personnel Bulletin 21-01 — Paid Parental Leave
• Kansas Department of Administration — FMLA
• K.S.A. § 44-1001 et seq. — Kansas Act Against Discrimination

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