FMLA Leave Request Form - Maine

FMLA LEAVE REQUEST FORM — MAINE

Use this form to record the employee's requested leave and the employer's separate review under federal FMLA, Maine family medical leave, Maine PFML, and any employer policy. Checking a box does not require the employee to decide which law applies.

1. Employee Information

2. Requested Leave

Requested schedule:

☐ Continuous leave

☐ Intermittent leave in separate blocks of time

☐ Reduced work schedule

3. Reason for Leave

Check all factual reasons that apply. The employer must evaluate each selected reason under each potentially applicable program.

☐ The employee has a serious health condition that makes the employee unable to work.

☐ The employee needs to care for a family member with a serious health condition.

Family member's name: [________________________________]

Relationship to employee: [________________________________]

☐ Birth of a child and bonding with the child.

☐ Placement of a child for adoption and bonding with the child.

☐ Placement of a child for foster care and bonding with the child. (Federal FMLA and Maine PFML may apply; Maine's unpaid family medical leave adoption ground in 26 M.R.S. § 843(4)(C) does not include foster placement.)

☐ The employee is donating an organ for a human organ transplant. (Maine family medical leave.)

☐ A spouse, domestic partner, parent, sibling, or child died or incurred a serious health condition while serving on active duty in the Maine military forces or United States Armed Forces. (Maine family medical leave.)

☐ A qualifying exigency arises from a covered family member's covered active duty or impending call or order to covered active duty.

☐ The employee needs to care for a covered servicemember with a serious injury or illness.

☐ The employee needs safe leave because the employee or a family member is a victim of violence, assault, sexual assault, stalking, or conduct that could support a Maine protection order. (Maine PFML.)

☐ Other reason potentially covered by law or employer policy: [________________________________]

4. Supporting Documentation

This request form is not a medical certification and should not be used to collect a diagnosis or detailed medical history. Use the applicable certification or PFML claim process separately.

☐ Certification is attached.

☐ Certification will be provided by [__/__/____].

☐ Employer has not requested certification.

☐ The request is not based on a reason requiring medical certification.

For federal FMLA, the employer may use the current U.S. Department of Labor certification forms identified in the Sources and References section.

5. Maine PFML Claim Information

Maine PFML is a separate wage-replacement program administered by the Maine Department of Labor or an approved private plan. The employee's benefit application does not replace notice to the employer.

☐ Employee intends to apply through Maine's PFML program.

☐ Employee intends to apply through the employer's approved private plan.

☐ Employee has applied; application or claim number: [________________________________]

☐ Employee does not presently intend to apply.

☐ Employee is uncertain and requests program information.

PFML determination status: ☐ Pending ☐ Approved ☐ Denied ☐ Not yet filed

Approved PFML dates, if known: [________________________________]

6. Employee Acknowledgment

I request leave for the dates and reason stated above. The information I provided is true and complete to the best of my knowledge. I understand that the employer will separately determine whether federal FMLA, Maine family medical leave, Maine PFML job protection, or an employer policy applies and may request legally permitted supporting documentation.

Employee signature: [________________________________]

Date: [__/__/____]

7. Employer Receipt

Employer representative signature: [________________________________]

Date: [__/__/____]

8. Employer Review — Federal FMLA

Federal coverage and eligibility must be determined independently from Maine law.

A. Employer Coverage

☐ Private employer employed 50 or more employees for each working day in at least 20 workweeks in the current or preceding calendar year.

☐ Public agency.

☐ Public or private elementary or secondary school or local educational agency.

☐ Federal FMLA employer coverage not established.

B. Employee Eligibility

C. Federal Determination

☐ Qualifying reason established.

☐ Qualifying reason not established.

☐ Federal FMLA designated for the following dates or schedule: [________________________________]

☐ Federal FMLA not designated; reason stated in separate notice: [________________________________]

Employer's 12-month measurement method:

☐ Calendar year

☐ Fixed 12-month leave year

☐ Twelve months measured forward from first FMLA use

☐ Rolling 12 months measured backward

9. Employer Review — Maine Family Medical Leave

Maine's family medical leave law generally provides up to 10 workweeks in any two-year period to an eligible employee. It is distinct from federal FMLA and Maine PFML.

A. Employer and Worksite Coverage

☐ Private employer employs at least 15 employees at one location in Maine.

☐ State employer.

☐ City, town, or municipal agency employs at least 25 employees.

☐ Other covered agent of an employer, the State, or a political subdivision.

☐ Employee is employed at a permanent worksite with at least 15 employees.

☐ Coverage not established.

B. Employee Eligibility and Reason

☐ Employee has been employed by the same employer for 12 consecutive months.

☐ Employee has not been employed by the same employer for 12 consecutive months.

☐ School-administrative-unit employee worked at least 900 hours in the previous 12 months; review the special rule in 26 M.R.S. § 844(4).

☐ A qualifying reason under 26 M.R.S. § 843(4) is established.

☐ A qualifying reason is not established.

C. Maine Leave Determination

☐ Maine family medical leave approved for: [________________________________]

☐ Maine family medical leave not approved; reason: [________________________________]

Notice review: Maine family medical leave ordinarily requires at least 30 days' notice of the intended start and end dates unless a medical emergency prevented that notice.

10. Employer Review — Maine PFML

Maine PFML may provide up to 12 weeks of family and medical leave in the aggregate during a benefit year. Maine's administrator or an approved private plan determines benefit eligibility and benefits.

PFML notice review: absent an emergency, illness, or other sudden necessity, the employee must give reasonable notice to the employee's supervisor. Record any notice issue and the applicable program determination: [________________________________]

11. Coordination, Benefits, and Return to Work

A. Concurrent Leave

Under 26 M.R.S. § 850-B(11), Maine PFML runs concurrently with federal FMLA and Maine family medical leave when the same absence qualifies under those laws.

☐ Federal FMLA and Maine PFML run concurrently for: [________________________________]

☐ Maine family medical leave and Maine PFML run concurrently for: [________________________________]

☐ Federal FMLA and Maine family medical leave run concurrently for: [________________________________]

☐ Programs do not fully overlap; explanation: [________________________________]

B. Health Coverage and Other Paid Leave

Federal FMLA rules may permit substitution of accrued paid leave. Maine PFML does not allow an employer to compel an employee to exhaust sick, vacation, or personal time before or while taking PFML. Apply the correct rule to each program and any employer policy.

C. Return to Work

☐ Federal FMLA restoration to the same or an equivalent position applies, subject to applicable law.

☐ Maine family medical leave restoration under 26 M.R.S. § 845 applies.

☐ Maine PFML restoration under 26 M.R.S. § 850-J applies.

☐ Fitness-for-duty certification will be required under a uniformly applied federal FMLA policy and was stated in the rights-and-responsibilities notice.

☐ Return-to-work requirements or limitations: [________________________________]

Expected return date: [__/__/____]

Position on return: [________________________________]

Employer representative signature: [________________________________]

Date: [__/__/____]

12. Sources and References

• Maine Legislature — 26 M.R.S. § 843, Definitions
• Maine Legislature — 26 M.R.S. § 844, Family Medical Leave Requirement
• Maine Legislature — 26 M.R.S. § 845, Employee Benefits Protection
• Maine Legislature — 26 M.R.S. § 850-A, PFML Definitions
• Maine Legislature — 26 M.R.S. § 850-B, PFML Program
• Maine Legislature — 26 M.R.S. § 850-H, Approved Private Plans
• Maine Legislature — 26 M.R.S. § 850-I, PFML Notice
• Maine Legislature — 26 M.R.S. § 850-J, PFML Return to Work
• Maine Department of Labor — Paid Family and Medical Leave
• U.S. Department of Labor — Family and Medical Leave Act
• U.S. Department of Labor — FMLA Forms
• eCFR — 29 C.F.R. Part 825
• U.S. House Office of the Law Revision Counsel — 29 U.S.C. Chapter 28

This document is a template only and does not constitute legal advice. Legal review is strongly recommended before use.