FMLA Leave Request Form - Minnesota
FMLA LEAVE REQUEST FORM — MINNESOTA
Table of Contents
- Employee Information
- Employer Information
- Type of Leave Requested
- Federal FMLA Overview
- Leave Schedule and Dates
- Intermittent or Reduced Schedule Leave
- Medical Certification
- Minnesota-Specific Considerations
- Job Restoration Rights
- Benefits During Leave
- Employee Certification and Signature
- Employer Response
- Sources and References
1. Employee Information
| Field | Entry |
|---|---|
| Full Legal Name | [________________________________] |
| Employee ID / Badge Number | [________________________________] |
| Department | [________________________________] |
| Job Title | [________________________________] |
| Hire Date | [__/__/____] |
| Work Location | [________________________________] |
| Direct Supervisor | [________________________________] |
| Phone Number | [________________________________] |
| Email Address | [________________________________] |
2. Employer Information
| Field | Entry |
|---|---|
| Company / Organization Name | [________________________________] |
| HR Contact Name | [________________________________] |
| HR Phone Number | [________________________________] |
| HR Email Address | [________________________________] |
| Company Address | [________________________________] |
| Total Employees in Minnesota | [________________________________] |
| Total Employees (within 75 miles for FMLA) | [________________________________] |
3. Type of Leave Requested
Please check the applicable reason for leave:
☐ Medical Leave (Employee) — Employee's own serious health condition, including pregnancy, childbirth, and recovery (up to 12 weeks under MN Paid Leave).
☐ Family Leave — Care for Family Member — To care for a family member with a serious health condition (up to 12 weeks under MN Paid Leave).
☐ Family Leave — Bonding with New Child — For the birth, adoption, or foster placement of a child and bonding within 12 months (up to 12 weeks under MN Paid Leave).
☐ Safety Leave — To address the effects of domestic abuse, sexual assault, or stalking against the employee or a family member (up to 12 weeks under MN Paid Leave).
☐ Qualifying Exigency (Military) — For any qualifying exigency arising from a family member's active military duty (up to 12 weeks under MN Paid Leave).
☐ Military Caregiver Leave — To care for a covered servicemember with a serious injury or illness (up to 26 weeks under federal FMLA).
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.
- Employee eligibility: 12 months of service, 1,250 hours worked, 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
| Field | Entry |
|---|---|
| Requested Leave Start Date | [__/__/____] |
| Anticipated Return Date | [__/__/____] |
| Total Leave Duration Requested | [________________________________] |
| Is this a foreseeable leave? | ☐ Yes ☐ No |
Federal FMLA: 30 days' advance notice if foreseeable.
Minnesota Paid Leave: 30 days' advance notice if foreseeable; as soon as practicable if not foreseeable.
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:
| Field | Entry |
|---|---|
| Estimated frequency of leave | [________________________________] |
| Estimated duration of each episode | [________________________________] |
| Proposed reduced schedule (if applicable) | [________________________________] |
7. Medical Certification
☐ Medical certification is attached.
☐ Medical certification will be provided by: [__/__/____]
Certifying Health Care Provider:
| Field | Entry |
|---|---|
| Provider Name | [________________________________] |
| Provider Phone Number | [________________________________] |
| Provider Address | [________________________________] |
8. Minnesota-Specific Considerations
Minnesota Paid Leave Law (Minn. Stat. ch. 268B)
Effective January 1, 2026, Minnesota's Paid Leave program provides comprehensive paid leave benefits:
Leave Entitlements:
- Medical Leave: Up to 12 weeks per benefit year for the employee's own serious health condition, including pregnancy and childbirth.
- Family Leave: Up to 12 weeks per benefit year for bonding with a new child, caring for a family member with a serious health condition, safety leave (domestic abuse/sexual assault/stalking), or qualifying military exigency.
- Combined maximum: Up to 20 weeks per benefit year when an employee qualifies for both medical and family leave.
Benefits, Premiums, and Financial Eligibility:
- Weekly benefit amounts are calculated under Minn. Stat. § 268B.04 and are subject to the current state maximum.
- Premium rates and permitted employee deductions may change; use the current Minnesota Paid Leave rate published by DEED.
- DEED or the approved private-plan administrator determines financial and leave eligibility. Employers should not promise a fixed benefit amount in this request form.
Expanded Family Definition:
Under MN Paid Leave, "family member" includes spouse, registered domestic partner, child (any age), parent, sibling, grandchild, grandparent, and other individuals with a close association equivalent to a family relationship.
Bonding Leave for 2025 Births
Parents who welcomed a child in 2025 may qualify for paid bonding leave benefits in 2026, provided the application is approved within 12 months of the child's arrival (birth, adoption, or foster placement).
Minnesota Parenting Leave Act (Minn. Stat. § 181.940–181.944)
The Minnesota Parenting Leave Act provides additional unpaid leave protections:
- Employer threshold: Employers with one or more employees.
- Leave duration: Up to 12 weeks of unpaid leave for the birth or adoption of a child.
- Eligibility: Minnesota law no longer imposes the former 12-month-service or half-time threshold.
- Job protection: Employees are entitled to restoration to the same or comparable position.
- School conference leave: Employees may take up to 16 hours per 12-month period for school conferences and activities.
Pregnancy and Lactation Accommodations (Minn. Stat. § 181.939)
Minnesota law requires covered pregnancy and childbirth accommodations, reasonable paid lactation breaks, and an appropriate private lactation space. These rights are separate from parenting leave, FMLA, Minnesota Paid Leave, and ESST.
Minnesota Paid Leave Application
Employee intends to apply for Minnesota Paid Leave benefits:
☐ Yes — through the Minnesota Paid Leave system (paidleave.mn.gov).
☐ No — employee will use accrued paid leave or take unpaid leave only.
Coordination of Leave Programs
| Leave Program | Duration | Paid/Unpaid | Runs Concurrently |
|---|---|---|---|
| Federal FMLA | 12 weeks/year | Unpaid | ☐ Yes ☐ No |
| MN Paid Leave — Medical | Up to 12 weeks/year | Paid | ☐ Yes ☐ No |
| MN Paid Leave — Family | Up to 12 weeks/year | Paid | ☐ Yes ☐ No |
| MN Parenting Leave Act | 12 weeks | Unpaid | ☐ Yes ☐ No |
Additional Employer Policies:
☐ Employer offers supplemental paid leave: [________________________________]
☐ Employer does not offer supplemental paid leave beyond statutory requirements.
9. Job Restoration Rights
Under federal FMLA, eligible employees are entitled to restoration to the same or equivalent position.
Under Minnesota Paid Leave (Minn. Stat. ch. 268B), retaliation is prohibited and statutory job-restoration rights generally begin 90 calendar days after hire for approved or good-faith qualifying leave.
Under the Minnesota Parenting Leave Act, employees are entitled to restoration to the same or comparable position with the same pay, benefits, and conditions.
☐ Employee has been identified as a key employee under 29 C.F.R. § 825.218.
10. Benefits During Leave
| Benefit | Status During Leave |
|---|---|
| Group Health Insurance | ☐ Continues — employee must continue premium contributions |
| Dental / Vision Insurance | [________________________________] |
| Life Insurance | [________________________________] |
| Retirement Plan Contributions | [________________________________] |
| Accrual of Seniority | [________________________________] |
| MN Paid Leave Wage Replacement | ☐ Applying ☐ Approved — Weekly Benefit: $[____] |
| Paid Leave Substitution | ☐ Employee elects to supplement MN Paid Leave with accrued paid leave ☐ Employee will rely on MN Paid Leave benefits only |
Type and amount of accrued paid leave available:
| Leave Type | Hours / Days Available |
|---|---|
| Vacation / PTO | [________________________________] |
| Sick Leave | [________________________________] |
| Personal Leave | [________________________________] |
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:
- I may be eligible for Minnesota Paid Leave benefits providing wage replacement during qualifying leave.
- Federal FMLA leave may run concurrently with Minnesota Paid Leave.
- I must provide medical certification if requested.
- I must file an application with the Minnesota Paid Leave program to receive benefits.
- Misrepresentation of facts may result in disciplinary action and/or denial of benefits.
Employee Signature: [________________________________]
Date: [__/__/____]
12. Employer Response
| Field | Entry |
|---|---|
| Date Request Received | [__/__/____] |
| FMLA Eligibility Determination | ☐ Eligible ☐ Not Eligible |
| MN Paid Leave Determination | ☐ Approved ☐ Denied ☐ Pending DEED/private-plan determination |
| MN Parenting Leave Act Applies | ☐ Yes ☐ No ☐ N/A |
| Reason for Ineligibility (if applicable) | [________________________________] |
| Leave Designated as FMLA | ☐ Yes ☐ No |
| 12-Month Leave Year Method Used | ☐ Calendar Year ☐ Fixed Leave Year ☐ Rolling 12-Month ☐ 12 Months from First Use |
| FMLA Leave Already Used (current period) | [________________________________] |
| FMLA Leave Remaining | [________________________________] |
| Medical Certification Required | ☐ Yes ☐ No — Due by: [__/__/____] |
| Fitness-for-Duty Certification Required | ☐ Yes ☐ No |
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
- Minn. Stat. ch. 268B — Minnesota Paid Leave Law
- Minn. Stat. § 181.940–181.944 — Minnesota Parenting Leave Act
- Minnesota Paid Leave — Official Site
- Minnesota House — Family, Medical Leave Law Summary
This document is a template only and does not constitute legal advice. Legal review is strongly recommended before implementation. Minnesota employers should ensure compliance with all applicable federal and state employment laws, including coordination of federal FMLA, Minnesota Paid Leave, and the Parenting Leave Act.
About this template
- Last updated
- July 28, 2026
- Jurisdiction
- Minnesota
- Category
- Employment & HR
Legal authority
- 29 U.S.C. § 2601 et seq. (Federal Family and Medical Leave Act)
- 29 C.F.R. Part 825 (FMLA Regulations)
- Minn. Stat. ch. 268B (Minnesota Paid Leave Law)
- Minn. Stat. § 181.940–181.944 (Minnesota Parenting Leave Act)
- Minn. Stat. § 181.939 (Pregnancy and Lactation Accommodations)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
The statutes this template relies on are listed under Legal authority.
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