FMLA LEAVE REQUEST FORM — MICHIGAN

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. Michigan-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.

☐ 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 from a family member's active military 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).

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, and work at a location with 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.

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. Michigan-Specific Considerations

No State FMLA Supplement. Michigan has not enacted a state-level family or medical leave law that expands upon federal FMLA protections. Employees rely on federal FMLA and employer-provided leave policies.

No State Paid Family Leave Program. Michigan does not operate a state-funded paid family or medical leave insurance program. No payroll contributions are collected for state paid leave benefits. The Michigan Legislature considered SB 332 and SB 333 (Family Leave Optimal Coverage Act) in 2023-2024, but neither was enacted.

Michigan Earned Sick Time Act — ESTA (MCL § 408.961 et seq.)

Effective February 21, 2025, the ESTA replaced the former Paid Medical Leave Act and provides mandatory paid sick time:

Large Employers (11+ employees):
- Employees accrue 1 hour of paid sick time for every 30 hours worked.
- Employees may use up to 72 hours of paid earned sick time per year.

Small Employers (1–10 employees):
- Employees accrue 1 hour of paid sick time for every 30 hours worked.
- Employees may use up to 40 hours of paid sick time per year, plus an additional 32 hours of unpaid sick time per year.
- Small employer obligations took effect October 1, 2025.

ESTA Qualifying Reasons:
- Employee's own mental or physical illness, injury, or health condition.
- Care for a family member's mental or physical illness, injury, or health condition.
- Medical appointments for the employee or a family member.
- Closure of the employee's workplace or the child's school/care facility due to a public health emergency.
- Domestic violence or sexual assault affecting the employee or a family member.

Will ESTA paid sick time be used during this leave?

☐ Yes — Hours available: [________________________________]
☐ No

Michigan Persons with Disabilities Civil Rights Act (MCL § 37.1101 et seq.)

Michigan law prohibits employment discrimination based on disability and requires reasonable accommodations:

• Employer threshold: Applies to employers with one (1) or more employees.
• Accommodation: Reasonable accommodations, including leave, may be required for qualifying disabilities.
• Pregnancy: Michigan courts have recognized pregnancy-related conditions as potentially qualifying for accommodation under this statute.

Michigan Workers' Disability Compensation

If the serious health condition is work-related, the employee may have concurrent rights under Michigan Workers' Disability Compensation Act (MCL § 418.101 et seq.). FMLA leave and workers' compensation may run concurrently.

Additional Employer Policies:

☐ Employer offers supplemental paid leave: [________________________________]
☐ Employer does not offer supplemental paid leave beyond FMLA and ESTA.

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.

☐ 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 may use earned sick time under the Michigan ESTA for qualifying reasons during FMLA 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.
• Misrepresentation of facts 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
• MCL § 408.961 et seq. — Michigan Earned Sick Time Act
• MCL § 37.1101 et seq. — Michigan Persons with Disabilities Civil Rights Act
• NOLO — Family and Medical Leave in Michigan

This document is a template only and does not constitute legal advice. Legal review is strongly recommended before implementation. Michigan employers should ensure compliance with all applicable federal and state employment laws, including the Earned Sick Time Act.