FMLA Leave Request Form - Kentucky
FMLA LEAVE REQUEST FORM — KENTUCKY
To: [EMPLOYER / HUMAN RESOURCES CONTACT]
From: [EMPLOYEE NAME]
Date: [__/__/____]
I request leave for the reason and schedule below. Please determine whether I am eligible for federal Family and Medical Leave Act (FMLA) leave and send the applicable eligibility, rights, responsibilities, and designation notices. I also request consideration under the separate Kentucky adoption-leave provision if I checked that box.
Employee information
| Field | Entry |
|---|---|
| Full name | [________________________________] |
| Employee ID, if used | [________________________________] |
| Job title and department | [________________________________] |
| Work location | [________________________________] |
| Hire date | [__/__/____] |
| Preferred contact information | [________________________________] |
Reason for leave
Check all that apply and provide only the information needed to identify the leave reason. Send medical certification or sensitive details through the employer's designated confidential process.
☐ My own serious health condition prevents me from performing my job.
☐ I need to care for my ☐ spouse ☐ child ☐ parent with a serious health condition.
☐ Birth of my child and care for or bonding with the child.
☐ Placement of a child with me for ☐ adoption ☐ foster care and care for or bonding with the child.
☐ A qualifying exigency involving my ☐ spouse ☐ child ☐ parent on covered military duty.
☐ Care for a covered servicemember with a serious injury or illness. My relationship is [________________________________].
Brief facts needed to identify the leave category: [____________________________________________]
Requested schedule
| Field | Entry |
|---|---|
| First day of leave | [__/__/____] |
| Estimated last day of leave | [__/__/____] |
| Expected return date, if known | [__/__/____] |
| Schedule | ☐ Continuous ☐ Intermittent ☐ Reduced schedule |
| If intermittent or reduced, expected frequency and duration | [________________________________] |
| Date I first learned leave would be needed | [__/__/____] |
| Prior FMLA leave in the employer's current leave year, if known | [________________________________] |
I will update the employer if the expected dates or frequency change. If supporting certification is requested, I will provide it through the employer's stated process by the communicated deadline or explain promptly if more time is needed.
Kentucky adoption leave, if applicable
☐ I also make a written request for personal leave under KRS 337.015 because I will receive an adoptive child under age ten on or about [__/__/____]. The adoption is [describe: ________________________________________________].
KRS 337.015(1) calls for reasonable personal leave up to six weeks; if the employer's birth-parent time-off policy exceeds six weeks, that longer period is the minimum available to qualifying adoptive parents. Under subsection (2), paid leave and other benefits provided to birth parents after a birth must be provided in the same type, amount, and duration following adoption. Subsection (3) excludes the specified fictive-kin, stepparent, stepsibling, blood-relative, and existing foster-parent adoptions. This Kentucky request is separate from the federal FMLA eligibility decision.
Birth-parent leave policy or benefit information, if known: [________________________________]
Employee signature
I certify that the facts I supplied in this request are accurate to the best of my knowledge. This form requests leave; it does not replace any certification or notice the employer may require or issue under applicable law.
Employee signature: ________________________________________
Date: [__/__/____]
Employer receipt and response
| Field | Entry |
|---|---|
| Date request received | [__/__/____] |
| HR contact | [________________________________] |
| Federal FMLA eligibility determination and notice date | [________________________________] |
| Certification requested and due date, if applicable | [________________________________] |
| Federal FMLA designation and notice date | [________________________________] |
| Kentucky adoption-leave decision and reasons, if requested | [________________________________] |
| Approved schedule or next step | [________________________________] |
Employer representative: ________________________________________
Date: [__/__/____]
About this template
- Last updated
- October 4, 2026
- Citations checked
- October 4, 2026
- Jurisdiction
- Kentucky
- Category
- Employment & HR
Legal authority
- 29 U.S.C. § 2611(2)
- 29 U.S.C. § 2612(a)
- KRS 337.015
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 4, 2026.
29 U.S.C. § 2611(2)(A) (checked October 4, 2026): "for at least 12 months by the employer with respect to whom leave is requested under section 2612 of this title; and"
29 U.S.C. § 2611(2)(A)(ii) (checked October 4, 2026): "for at least 1,250 hours of service with such employer during the previous 12-month period."
29 U.S.C. § 2612(a)(1) (checked October 4, 2026): "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:"
KRS 337.015(1) (checked October 4, 2026): "Upon receiving written request by an employee, every employer shall grant reasonable personal leave not to exceed six (6) weeks"
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