FMLA Leave Request Form - Louisiana

FMLA AND LOUISIANA LEAVE REQUEST FORM

[EMPLOYER LEGAL NAME]

Use this intake form to report a need for leave. An Employee does not need to know whether the FMLA or a Louisiana leave law applies. Human Resources—not the Employee—must evaluate coverage, eligibility, designation, concurrency, accommodation, and any right provided by a more protective law or policy.

Effective-date alert: Louisiana Act 506 becomes effective August 1, 2026 and adds living-organ and bone-marrow donor leave rules. Human Resources must use the pre-August 1 or post-August 1 rule based on the requested leave dates.

1. EMPLOYEE INFORMATION

2. LEAVE REASON

Check all that may apply. Do not include a diagnosis or detailed genetic information on this intake form.

☐ Employee's own serious health condition

☐ Care for a spouse, child, or parent with a serious health condition

☐ Birth of a child and bonding

☐ Placement of a child for adoption or foster care and bonding

☐ Pregnancy, childbirth, lactation, or a related medical condition

☐ Qualifying exigency related to covered military duty

☐ Care for a covered servicemember with a serious injury or illness

☐ Bone marrow donation

☐ Living-organ donation

☐ Other potentially protected leave or accommodation need: [________________________]

3. REQUESTED DATES AND SCHEDULE

FMLA leave may be taken intermittently or on a reduced schedule in circumstances permitted by 29 C.F.R. § 825.202. Medical necessity, employer agreement for bonding leave, and qualifying-exigency rules differ. Human Resources must not approve or deny an intermittent schedule from this checkbox alone.

4. NOTICE

For foreseeable FMLA leave, an Employee generally must provide at least thirty days' advance notice when practicable. If thirty days is not practicable or the need is unforeseeable, notice must be provided as soon as practicable under 29 C.F.R. §§ 825.302-825.303. An Employee need not use the term “FMLA,” but must provide enough information for the employer to evaluate whether leave may qualify.

5. CERTIFICATION AND SUPPORTING INFORMATION

Human Resources will identify any permitted certification and provide the applicable deadline. Do not attach medical records unless specifically and lawfully requested.

☐ Human Resources provided a certification form

☐ Certification attached

☐ Certification will be returned by: [__/__/____]

☐ No certification requested

When certification is requested, the FMLA generally allows at least fifteen calendar days to provide it, absent circumstances described in 29 C.F.R. § 825.305. The Company will accept a complete and sufficient certification in any format permitted by current FMLA rules and will not require information beyond what those rules permit.

6. LOUISIANA PREGNANCY, CHILDBIRTH, AND LACTATION REVIEW

La. R.S. 23:341-342 applies to an employer that employs more than twenty-five Employees in Louisiana for the statutory period. Human Resources must also evaluate the federal Pregnant Workers Fairness Act and any law or policy providing greater protection.

For a covered Louisiana employer:

• pregnancy, childbirth, and related medical conditions are treated as temporary disability subject to the statute;
• an Employee must receive the same benefits and privileges provided to other Employees similar in their ability or inability to work;
• pregnancy leave is six weeks for a normal pregnancy and childbirth or the period of disability caused by pregnancy, childbirth, or a related medical condition, but not more than four months;
• accrued annual leave may be used during that period;
• reasonable accommodation is required for known covered limitations unless the employer establishes undue hardship;
• the employer may not require leave if another required reasonable accommodation can be provided; and
• if the employer transfers other temporarily disabled Employees under a policy, practice, or collective bargaining agreement, it may not refuse a pregnant Employee's request for a qualifying transfer.

Lactation and the need to express breast milk for up to one year after birth are related medical conditions under La. R.S. 23:341.1. The Employee may request compensated breaks and a private place other than a bathroom stall as an accommodation. Separate federal lactation rules may also apply.

7. LOUISIANA DONOR-LEAVE REVIEW

7.1 Current Paid Bone-Marrow Leave

La. R.S. 40:1263.4 covers an employer with twenty or more Employees at at least one site and an Employee who averages twenty or more work hours per week. A covered employer must grant paid leave for a medical procedure to donate bone marrow. The combined leave may not exceed forty work hours unless the employer agrees to more. The employer may require physician verification of purpose and length and may not retaliate for a protected request or leave.

7.2 Act 506 — Effective August 1, 2026

Beginning August 1, 2026, La. R.S. 40:1264.2 will:

• define “private employer” as a listed private entity with one or more Employees and direct a private employer to grant written-request unpaid leave for “an employee” to serve as a living-organ or bone-marrow donor;
• state that the private-employer leave length is “equal to the time requested by the employee or thirty consecutive calendar days” without adding a “whichever is less” or “whichever is greater” instruction;
• prohibit discharge, demotion, suspension, threats, harassment, or discrimination for requesting or obtaining protected donor leave; and
• provide qualifying full-time state-agency Employees with paid leave of up to thirty consecutive calendar days beginning the day after living-organ donation surgery, with the statutory FMLA-concurrency rule.

Act 506 separately defines “Employee” as a qualifying full-time state-agency Employee even though its private-employer provision also uses that defined term. The existing paid bone-marrow rule and Act 506 may overlap after August 1. Because of those textual issues, Human Resources must have Louisiana counsel determine private-sector eligibility, duration, pay status, and concurrency; this form does not reduce either entitlement.

8. STATE CIVIL SERVICE PARENTAL LEAVE

Complete only for an Employee covered by the Louisiana State Civil Service parental-leave program. Current official guidance provides up to six weeks (240 hours for a full-time eligible Employee) during the twelve-week period after a qualifying birth, adoption, or foster placement, paid at 100% of base pay. Eligibility includes a leave-earning position, twelve months of state service, 1,250 hours physically worked during the preceding twelve months, and an active ongoing parenting role.

☐ Not applicable — private-sector or otherwise outside program coverage

☐ State Civil Service program reviewed; agency certification form provided

9. FMLA ELIGIBILITY AND EMPLOYER RESPONSE

An FMLA-covered employer must provide the eligibility notice within five business days after an Employee requests FMLA leave or the employer learns that leave may be FMLA-qualifying, absent extenuating circumstances. Human Resources should use current DOL Form WH-381 or a compliant equivalent and, after obtaining enough information, Form WH-382 or a compliant designation notice.

10. BENEFITS AND RESTORATION

During FMLA leave, group health coverage must be maintained on the same conditions as if the Employee had continued working. The Employee remains responsible for the Employee share of premiums under the arrangements stated in the rights-and-responsibilities notice.

On return from FMLA leave, an eligible Employee is generally entitled to the same position or an equivalent position with equivalent pay, benefits, and other terms and conditions, subject to the FMLA's specific limitations. A “key Employee” designation by itself does not eliminate restoration; Human Resources must satisfy the notice and substantial-and-grievous-economic-injury requirements before relying on that limitation.

Louisiana pregnancy law must not be described as creating the same automatic restoration rule as the FMLA. Human Resources must instead apply its nondiscrimination, leave, benefit, transfer, accommodation, and anti-adverse-action requirements, together with any overlapping FMLA or other restoration right.

11. EMPLOYEE CERTIFICATION

I certify that the information I provided on this request is true and complete to the best of my knowledge. I understand that Human Resources will determine which law or policy applies and may request only the supporting information permitted by that law or policy. I will notify Human Resources if the dates, schedule, or reason for leave materially changes.

Employee Signature: [________________________________]

Date: [__/__/____]

12. HUMAN RESOURCES CERTIFICATION

I reviewed this request for FMLA, Louisiana pregnancy, donor-leave, State Civil Service, accommodation, benefit-plan, collective-bargaining, and local-law issues that may apply. Any approval, denial, designation, certification request, pay determination, or restoration decision will be communicated separately in writing.

HR Representative: [________________________________]

Title: [________________________________]

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

Sources and References

• 29 U.S.C. § 2611 — FMLA Definitions and Eligibility
• 29 U.S.C. § 2612 — FMLA Leave
• 29 U.S.C. § 2614 — FMLA Benefits and Restoration
• 29 U.S.C. § 218d — Federal Lactation Breaks and Space
• 29 C.F.R. §§ 825.100, 825.104, and 825.110 — FMLA Coverage and Eligibility
• 29 C.F.R. §§ 825.200 and 825.202 — Amount and Schedule of FMLA Leave
• 29 C.F.R. §§ 825.209, 825.214, and 825.218 — Benefits and Restoration
• 29 C.F.R. §§ 825.300-825.303 and 825.305 — Employer and Employee Notices and Certification
• 42 U.S.C. §§ 2000gg to 2000gg-1 — Pregnant Workers Fairness Act
• U.S. Department of Labor — Current Optional FMLA Forms
• La. R.S. 23:341 — Pregnancy-Law Coverage
• La. R.S. 23:341.1 — Pregnancy-Accommodation Definitions
• La. R.S. 23:342 — Pregnancy Leave and Accommodation
• La. R.S. 40:1263.4 — Paid Bone-Marrow-Donor Leave
• 2026 La. Acts No. 506 — Living-Organ and Bone-Marrow Donor Leave
• Louisiana Legislature — SB 409 / Act 506 Status and August 1, 2026 Effective Date
• Louisiana State Civil Service — Parental Leave