FMLA Leave Request Form - Missouri
FMLA LEAVE REQUEST FORM — MISSOURI
To: [________________________________] (employer or HR contact)
Date submitted: [__/__/____]
Employee and worksite
| Field | Entry |
|---|---|
| Employee name | [________________________________] |
| Employee ID, if any | [________________________________] |
| Job title / department | [________________________________] |
| Employer name | [________________________________] |
| Missouri worksite address | [________________________________] |
| Hire date | [__/__/____] |
| Phone / email for leave communications | [________________________________] |
Reason for requested leave
I request leave for the reason checked below. I understand that the employer will determine whether this request qualifies for FMLA leave.
☐ My own serious health condition makes me unable to perform my job functions.
☐ I need to care for my spouse, son or daughter, or parent with a serious health condition. Relationship: [________________________________]
☐ Birth of my child and care for the child.
☐ Placement of a child with me for adoption or foster care.
☐ A qualifying exigency arising from my spouse's, son or daughter's, or parent's covered active military duty or notice of an impending call or order to covered active duty. Relationship: [________________________________]
☐ Care for a covered servicemember with a serious injury or illness. My relationship to the servicemember: [________________________________]
Additional facts needed to identify the leave reason, without diagnosis or detailed medical history: [________________________________]
Requested schedule
First date of leave: [__/__/____]
Expected return or end date, if known: [__/__/____]
Schedule requested: ☐ Continuous leave ☐ Intermittent leave ☐ Reduced work schedule
If intermittent or reduced, expected frequency, duration, and work schedule: [________________________________]
Date I first knew leave would be needed: [__/__/____]
If the request is made close to the start date, reason advance notice was not practicable: [________________________________]
Expected changes or follow-up information: [________________________________]
Certification and paid leave
If the employer requests a separate certification for this leave: ☐ I will provide it by the deadline the employer gives me ☐ I have provided it ☐ I need information about the required form or deadline
Employer policy or other paid leave I want reviewed for possible use during this absence: [________________________________]
Best way and time to contact me about this request: [________________________________]
I certify that the information I provided in this request is accurate to the best of my knowledge. I will notify the employer if my expected leave schedule changes.
Employee signature: [________________________________] Date: [__/__/____]
Employer receipt and follow-up
Received by: [________________________________] Date received: [__/__/____]
Eligibility and rights notice provided separately: ☐ Yes, date [__/__/____] ☐ Pending
Certification requested separately: ☐ Yes, date [__/__/____] ☐ No
Designation notice provided separately: ☐ Yes, date [__/__/____] ☐ Pending
Follow-up contact and date: [________________________________]
This request records the employee's stated reason and schedule. Eligibility, certification, available leave, pay substitution, health coverage, and restoration are determined under the applicable FMLA provisions, regulations, and employer policy. See 29 U.S.C. §§ 2611–2614 and the U.S. Department of Labor FMLA fact sheet.
About this template
- Last updated
- October 7, 2026
- Citations checked
- October 7, 2026
- Jurisdiction
- Missouri
- Category
- Employment & HR
Legal authority
- 29 U.S.C. § 2611(2)
- 29 U.S.C. § 2612(a), (b), (e)
- 29 U.S.C. § 2613(a)
- 29 U.S.C. § 2614(a), (c)
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
A reviewer verified this template's legal citations against the official source on October 7, 2026.
29 U.S.C. § 2611(2)(A)(ii) (checked September 30, 2026): "for at least 1,250 hours of service with such employer during the previous 12-month period."
29 U.S.C. § 2611(2) (checked October 7, 2026): "The term "eligible employee" means an employee who has been employed— (i) for at least 12 months by the employer with respect to whom leave is requested under section 2612 of this title; and (ii) for at least 1,250 hours of service with such employer during the previous 12-month period."
29 U.S.C. § 2612(a), (b), (e) (checked October 7, 2026): "Subject to section 2613 of this title and subsection (d)(3), an eligible employee shall be entitled to a total of 12 workweeks of leave during any 12-month period for one or more of the following:"
29 U.S.C. § 2613(a) (checked October 7, 2026): "An employer may require that a request for leave under subparagraph (C) or (D) of paragraph (1) or paragraph (3) of section 2612(a) of this title be supported by a certification issued by the health care provider"
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