FMLA LEAVE REQUEST FORM — LOUISIANA

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. Louisiana-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.

☐ Pregnancy, Childbirth, or Related Medical Condition — Disability related to pregnancy, childbirth, or related conditions (see Louisiana pregnancy disability leave in Section 8).

☐ 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.

☐ 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).

☐ Bone Marrow Donor Leave — Leave for the purpose of donating bone marrow (see Section 8).

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. Louisiana-Specific Considerations

Louisiana Pregnancy Disability Leave (La. R.S. § 23:341–23:342)

Louisiana law provides significant protections for employees affected by pregnancy, childbirth, and related medical conditions:

• Employer threshold: Applies to employers with twenty-five (25) or more employees — lower than the federal FMLA 50-employee threshold.
• Duration: A "reasonable period of time" not to exceed four (4) months for pregnancy disability. For a normal pregnancy and childbirth, the standard leave period is six (6) weeks.
• Equal treatment: Employers must treat pregnancy, childbirth, and related medical conditions the same as any other temporary disability for all employment-related purposes.
• Leave and benefits: Employees are entitled to receive the same benefits or privileges of employment granted to other temporarily disabled employees, including disability leave, sick leave, or other accrued leave.
• Transfer: An employer may not require transfer to a different position during pregnancy unless the employee's physician certifies the transfer is medically necessary.
• No retaliation: An employer may not refuse to hire, discharge, or otherwise discriminate against a woman affected by pregnancy, childbirth, or related medical conditions.

Is this leave request related to pregnancy, childbirth, or a related condition?

☐ Yes — La. R.S. § 23:341–342 protections may apply.
☐ No

Bone Marrow Donor Leave (La. R.S. § 23:1015 et seq.)

Louisiana law requires employers with 20 or more employees to grant up to 40 hours of paid leave per year to employees who donate bone marrow. This leave is in addition to any FMLA entitlement.

☐ This request is for bone marrow donor leave.

No State Paid Family Leave Program

Louisiana does not operate a state-funded paid family or medical leave insurance program for private-sector employees. No payroll contributions are collected for state paid leave benefits.

State Employee Paid Parental Leave (Civil Service Rule 11.36)

Louisiana classified state employees are eligible for up to six (6) weeks of paid parental leave at 100% salary for the birth, adoption, or foster care placement of a child, effective January 1, 2024. This benefit does not apply to private-sector employees.

Louisiana Employment Discrimination Law (La. R.S. § 23:301 et seq.)

Louisiana law prohibits employment discrimination based on disability. Employers with 20 or more employees must provide reasonable accommodations for employees with disabilities under state law.

Additional Employer Policies. Employees should review their employer's handbook 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.

Under Louisiana pregnancy disability law (La. R.S. § 23:342), employees are entitled to be restored to the same or a comparable position.

☐ 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
• La. R.S. § 23:341–342 — Pregnancy Disability Leave
• La. R.S. § 23:1015 — Bone Marrow Donor Leave
• Louisiana Civil Service — Parental Leave
• NOLO — Family and Medical Leave in Louisiana

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