FMLA Leave Request Form

provide explanatory notes.
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FMLA LEAVE REQUEST FORM — MISSOURI

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. Missouri-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. Missouri-Specific Considerations

No State FMLA Supplement. Missouri has not enacted a state-level family or medical leave law that expands upon federal FMLA protections for private-sector employees.

No Mandatory Paid Family Leave Program. Missouri does not operate a state-funded mandatory paid family or medical leave insurance program. No mandatory payroll contributions are collected for state paid leave benefits.

No State Mandatory Paid Sick Leave. Missouri voters approved Proposition A in November 2024 establishing earned paid sick time; however, the Missouri Legislature repealed the paid sick leave provisions through HB 567, signed July 10, 2025, with the repeal effective August 28, 2025. As of April 2026, Missouri does not mandate paid sick leave.

Missouri Earned Family and Medical Leave Act (Voluntary Savings Program)

A voluntary savings program was established effective January 2025:

• Nature: Voluntary — employees may make payroll contributions to a family and medical leave savings account.
• Benefits: Workers are expected to be able to access saved benefits beginning January 2027.
• Not mandatory: Employer participation is optional and no employer contributions are required.

Does the employer participate in the Missouri Earned Family and Medical Leave savings program?

☐ Yes — Enrollment details: [________________________________]
☐ No
☐ Unknown

Missouri Human Rights Act (Mo. Rev. Stat. § 213.010 et seq.)

The Missouri Human Rights Act prohibits employment discrimination, including discrimination based on disability and sex (which includes pregnancy):

• Employer threshold: Applies to employers with six (6) or more employees.
• Pregnancy protections: Employers must treat pregnancy, childbirth, and related medical conditions the same as other temporary disabilities.
• Disability accommodation: Reasonable accommodations, including leave, may be required for qualifying disabilities.

Proposed Legislation

The Missouri Legislature has considered but not enacted paid family and medical leave bills in recent sessions, including SB 548 (Missouri Earned Family and Medical Leave Act) and SB 945 (Missouri Family and Medical Leave Program). These proposals have not been enacted as of April 2026.

Additional Employer Policies:

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

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.
• Missouri does not have a state-funded paid family leave program.
• 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
• Mo. Rev. Stat. § 213.010 et seq. — Missouri Human Rights Act
• NOLO — Family and Medical Leave in Missouri
• Missouri Senate — SB 548 (Proposed Earned Family and Medical Leave)

This document is a template only and does not constitute legal advice. Legal review is strongly recommended before implementation. Missouri employers should ensure compliance with all applicable federal and state employment laws.