FMLA Leave Request Form - Maryland

FAMILY AND MEDICAL LEAVE REQUEST

Maryland

[EMPLOYER NAME]

This form asks for information needed to identify potentially protected leave. An Employee does not need to know or name the governing law. The Employer, not the Employee, is responsible for determining coverage, eligibility, designation, required notices, and coordination of overlapping leave rights.

Do not request a diagnosis or genetic information on this form. Use the applicable U.S. Department of Labor certification form or a separately reviewed lawful certification process when certification is permitted.

1. EMPLOYEE AND EMPLOYER INFORMATION

2. LEAVE REASON

Check every description that may apply. Human Resources will determine which law or policy covers the request.

2.1 Federal FMLA reasons

☐ Employee's own serious health condition makes the Employee unable to perform one or more essential job functions.

☐ Care for the Employee's spouse, child, or parent with a serious health condition.

☐ Birth of the Employee's child and bonding within twelve months after birth.

☐ Placement of a child with the Employee for adoption or foster care and bonding within twelve months after placement.

☐ Qualifying exigency arising from the covered active duty or call to covered active duty of the Employee's spouse, child, or parent.

☐ Care for a covered servicemember with a serious injury or illness where the Employee is the servicemember's spouse, child, parent, or next of kin.

2.2 Maryland reasons that may apply separately or concurrently

☐ Birth of the Employee's child or placement for adoption or foster care under the Maryland Parental Leave Act.

☐ Use of earned paid leave for illness of the Employee's child, spouse, or parent under the Maryland Flexible Leave Act.

☐ Use of earned paid leave for bereavement after the death of the Employee's child, spouse, or parent under the Maryland Flexible Leave Act.

☐ Maryland earned sick and safe leave for the Employee or a covered family member, maternity or paternity leave, or a qualifying domestic-violence, sexual-assault, or stalking purpose.

☐ Future Maryland FAMLI qualifying event after benefits become available.

☐ Other Company, collective-bargaining, federal, State, or local leave: [________________________________]

Name and relationship of person needing care, if applicable: [________________________________]

Brief facts sufficient to identify the leave category, without a diagnosis:
[____________________________________________________________]
[____________________________________________________________]

3. LEAVE DATES AND SCHEDULE

If intermittent or reduced-schedule leave is requested:

For foreseeable federal FMLA leave, an Employee generally must give at least thirty days' advance notice. If thirty days is not practicable, notice is due as soon as practicable. The Employee need not mention “FMLA” but must provide enough information for the Employer to identify a potentially qualifying reason.

4. EMPLOYEE NOTICE AND DOCUMENTS

Preferred contact method during leave: [________________________________]

Mailing or email address for notices: [________________________________]

☐ I have attached available supporting information.

☐ A health-care-provider certification may be required. If the Employer requests one, the Employer will provide the applicable form and deadline.

☐ A military exigency or military caregiver certification may be required.

☐ I request that Human Resources contact me to discuss what information is needed.

An Employer that requires federal FMLA certification generally must give notice of that requirement. The Employee generally has fifteen calendar days after the request to return a complete and sufficient certification, unless diligent good-faith efforts cannot meet the deadline or the Employer allows more time. The Employer must identify an incomplete or insufficient certification in writing and provide the regulatory opportunity to cure.

5. PAID LEAVE AND BENEFIT COORDINATION

The Employee requests or reports the following available leave:

Employee preference, subject to governing law and policy:

☐ Use available paid leave concurrently with unpaid protected leave.

☐ Preserve paid leave to the extent permitted.

☐ Discuss coordination with Human Resources before election.

Federal FMLA is generally unpaid, but accrued paid leave may run concurrently when the statute, regulations, and policy permit. Disability or insurance benefits may replace wages without themselves expanding the amount of job-protected leave. Human Resources must document coordination under every applicable law, plan, and policy.

6. MARYLAND LEAVE REVIEW

6.1 Maryland Flexible Leave Act

Md. Code Ann., Lab. & Empl. § 3-802 applies to an Employee primarily employed in Maryland when the Employer provides earned leave with pay under a collective bargaining agreement or employment policy and has at least fifteen Employees for the statutory twenty-workweek period.

A covered Employee may use earned paid leave for illness of a child, spouse, or parent and for bereavement after the death of a child, spouse, or parent. The Employee chooses the type and amount of earned paid leave when more than one type is available, subject to an equal-or-greater policy or collective bargaining benefit and other statutory rules. The Act does not create additional paid leave or extend or limit federal FMLA entitlement.

Flexible Leave Act applies: ☐ Yes ☐ No ☐ More information needed

6.2 Maryland Parental Leave Act

Md. Code Ann., Lab. & Empl. §§ 3-1201 through 3-1205 generally cover an Employer with fifteen through forty-nine Employees in Maryland for the statutory period that is not covered by federal FMLA for the current year. Eligibility generally requires twelve months of employment, 1,250 hours in the prior twelve months, and the statute's worksite coverage.

A covered Employee may receive six workweeks of unpaid parental leave in a twelve-month period for birth or placement for adoption or foster care. Thirty days' written notice may be required, except following premature birth, unexpected adoption, or unexpected foster placement. Paid leave may substitute when permitted. Group-health coverage and restoration rights apply subject to the statute, including narrow economic-injury provisions that require counsel review before use.

Parental Leave Act applies: ☐ Yes ☐ No ☐ More information needed

6.3 Maryland Earned Sick and Safe Leave

An Employer with an average monthly workforce of fifteen or more Employees in the preceding year provides paid earned sick and safe leave; an Employer with fourteen or fewer provides at least unpaid leave. Covered Employees generally accrue at least one hour for every thirty hours worked, subject to statutory exclusions, caps, frontloading, carryover, use, notice, and verification rules.

Earned sick and safe leave applies: ☐ Yes ☐ No ☐ More information needed

6.4 Maryland FAMLI implementation alert

Maryland FAMLI benefits are not available as of this form's verification date. Current Maryland Department of Labor guidance states:

• Contributions and payroll deductions begin January 1, 2027.
• First quarterly wage-and-hour reports and payments are due in April 2027.
• Benefits become available January 1, 2028.
• Benefit eligibility generally requires at least 680 hours in a position localized in Maryland during the four reported calendar quarters before the claim or leave begins.
• When operative, the program can provide up to twelve weeks of job-protected paid leave annually, with benefits up to $1,000 per week, for qualifying medical, caregiving, parental, and uniformed-service events.

The Employer must use current paidleave.maryland.gov guidance for registration, plan selection, contributions, reporting, notices, claims, and coordination. This form does not promise FAMLI benefits before the operative date.

FAMLI status for this request:
☐ Not yet operative
☐ Contributions operative but benefits not yet available
☐ Benefits operative; separate current FAMLI process required

7. EMPLOYEE ACKNOWLEDGMENT

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

• this request does not itself approve, deny, or designate leave;
• Human Resources may request information or certification permitted by law;
• I should notify Human Resources as soon as practicable if the dates, duration, schedule, or reason changes; and
• I may contact a government agency or use another protected process without first completing an internal appeal.

If someone completed notice for an incapacitated Employee:

8. EMPLOYER REVIEW

8.1 Federal FMLA coverage and eligibility

Eligibility notice issued within the time required by 29 C.F.R. § 825.300: ☐ Yes
Date issued: [__/__/____]
If ineligible, reason stated in notice: [________________________________]

Rights-and-responsibilities notice issued: ☐ Yes
Date issued: [__/__/____]

Certification requested: ☐ Yes ☐ No
Form used: ☐ WH-380-E ☐ WH-380-F ☐ WH-384 ☐ WH-385 ☐ WH-385-V ☐ Other lawful form
Request date: [__/__/____] Due date: [__/__/____]
Certification received: ☐ Yes ☐ No ☐ Incomplete ☐ Insufficient
Written cure notice and cure period provided if required: ☐ Yes ☐ N/A

8.2 Entitlement and designation

Employer's FMLA twelve-month method:

☐ Calendar year
☐ Fixed twelve-month year: [________________________________]
☐ Twelve months measured forward from first FMLA leave
☐ Rolling twelve months measured backward

FMLA leave used in applicable period: [________________________________]
FMLA leave remaining: [________________________________]

Designation notice issued: ☐ Yes ☐ No ☐ Pending sufficient information
Date issued: [__/__/____]

Leave designated:

☐ Federal FMLA
☐ Maryland Parental Leave Act
☐ Maryland Flexible Leave Act paid-leave use
☐ Maryland earned sick and safe leave
☐ Company or collective-bargaining leave
☐ Other: [________________________________]
☐ Not designated; explanation provided separately

Paid leave will run concurrently: ☐ Yes ☐ No ☐ Partly
Health-benefit premium arrangements provided: ☐ Yes ☐ N/A
Periodic status reports required and disclosed: ☐ Yes ☐ No
Fitness-for-duty certification lawfully required and disclosed in designation notice: ☐ Yes ☐ No
Essential-function list timely provided if certification must address those functions: ☐ Yes ☐ N/A
Key-Employee notice lawfully applicable and issued: ☐ Yes ☐ No ☐ N/A

8.3 Decision and contacts

Approved dates or schedule:
[____________________________________________________________]

Information still needed:
[____________________________________________________________]

Human Resources contact for questions or changes: [________________________________]

9. OFFICIAL SOURCES

• Maryland Flexible Leave Act, Md. Code Ann., Lab. & Empl. § 3-802
• Maryland Parental Leave Act, Md. Code Ann., Lab. & Empl. §§ 3-1201 through 3-1205
• Maryland earned sick and safe leave, Md. Code Ann., Lab. & Empl. §§ 3-1301 through 3-1306
• Maryland FAMLI official program guidance
• Current federal FMLA regulations, 29 C.F.R. Part 825
• U.S. Department of Labor FMLA forms