FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & Montana Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | Mont. Code Ann. §§ 49-2-310 to 49-2-311)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Montana State Leave Provisions
5. Type of Leave Requested
6. Leave Schedule
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits During Leave
11. Montana-Specific Notices
12. Employee Certification & Signature
13. Employer Response
14. Sources and References

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. FEDERAL FMLA OVERVIEW

Eligibility Requirements (29 U.S.C. § 2611(2)):
- Employed by a covered employer (50+ employees within 75 miles)
- Worked for the employer for at least 12 months (need not be consecutive)
- Worked at least 1,250 hours during the 12 months preceding the leave
- Works at a location where the employer has 50+ employees within 75 miles

Leave Entitlement:
- Up to 12 workweeks of unpaid, job-protected leave in a 12-month period
- Up to 26 workweeks for military caregiver leave (29 U.S.C. § 2612(a)(3))

Qualifying Reasons (29 U.S.C. § 2612(a)(1)):
- ☐ Birth of a child and bonding within the first 12 months
- ☐ Placement of a child for adoption or foster care and bonding within the first 12 months
- ☐ Care for a spouse, child, or parent with a serious health condition
- ☐ Employee's own serious health condition rendering them unable to perform essential job functions
- ☐ Qualifying exigency arising from a family member's military service
- ☐ Care for a covered servicemember with a serious injury or illness (26 weeks)

4. MONTANA STATE LEAVE PROVISIONS

Montana Maternity Leave (Mont. Code Ann. § 49-2-310 and § 49-2-311):
- Montana law prohibits employment discrimination based on pregnancy and requires employers to provide reasonable maternity leave to female employees
- The leave must be for a "reasonable" period of time as determined by the employee's physician
- Applies to all employers regardless of size (unlike federal FMLA's 50-employee threshold)
- Protects the employee's right to return to her original position or an equivalent position
- Employers may not terminate or refuse to grant leave to a pregnant employee

No State Paid Family Leave Program:
- Montana does not currently operate a state-funded paid family and medical leave (PFML) program
- All FMLA leave in Montana is unpaid unless the employee elects (or employer requires) use of accrued paid leave

Volunteer Emergency Responders:
- Mont. Code Ann. § 10-3-1203 provides limited leave protections for volunteer emergency service providers responding to declared emergencies

5. TYPE OF LEAVE REQUESTED

Select all that apply:

☐ Birth of child / prenatal care / pregnancy-related incapacity
☐ Bonding with newborn child (within 12 months of birth)
☐ Placement of child for adoption or foster care
☐ Bonding with newly placed child (within 12 months of placement)
☐ Employee's own serious health condition
☐ Care for spouse with a serious health condition
☐ Care for child with a serious health condition
☐ Care for parent with a serious health condition
☐ Qualifying exigency — military deployment
☐ Military caregiver leave (26-week entitlement)
☐ Montana maternity leave under Mont. Code Ann. § 49-2-310

Name of family member (if applicable): [________________________________]
Relationship to employee: [________________________________]

Brief description of reason for leave:
[________________________________]
[________________________________]

6. LEAVE SCHEDULE

7. INTERMITTENT OR REDUCED SCHEDULE LEAVE

☐ Not applicable — I am requesting continuous leave

☐ Intermittent leave — I need to take leave in separate blocks of time

☐ Reduced schedule — I need to reduce my usual work schedule

If intermittent or reduced schedule leave is requested:

8. MEDICAL CERTIFICATION

☐ Medical certification is attached (DOL Form WH-380-E or WH-380-F)
☐ Medical certification will be provided by: [__/__/____]
☐ Military certification is attached (DOL Form WH-384 or WH-385)
☐ No medical certification required for this leave type

Certifying Healthcare Provider:

9. JOB RESTORATION RIGHTS

Federal FMLA Restoration (29 U.S.C. § 2614(a)):
- Employee is entitled to return to the same position or an equivalent position with equivalent pay, benefits, and working conditions
- Key employees (salaried, among the highest-paid 10%) may be subject to limited exceptions under 29 U.S.C. § 2614(b)

Montana Maternity Leave Restoration (Mont. Code Ann. § 49-2-310):
- Employee is entitled to return to her original position or a comparable position with equivalent pay and accumulated seniority
- This protection applies to all Montana employers regardless of size

10. BENEFITS DURING LEAVE

Health Insurance Continuation:
- Employer must maintain group health insurance under the same terms as if the employee continued to work (29 U.S.C. § 2614(c))
- Employee must continue to pay their share of premiums

Paid Leave Substitution:

☐ I elect to substitute accrued paid leave concurrently with FMLA leave
☐ I understand the employer may require substitution of accrued paid leave

11. MONTANA-SPECIFIC NOTICES

Montana Human Rights Act (Mont. Code Ann. Title 49, Chapter 2):
- Montana prohibits discrimination in employment based on sex, pregnancy, and marital status
- An employee who believes they have been denied leave or retaliated against may file a complaint with the Montana Human Rights Bureau within 180 days of the alleged discriminatory act
- Contact: Montana Human Rights Bureau, P.O. Box 1728, Helena, MT 59624 | Phone: (406) 444-2884

Montana Wrongful Discharge from Employment Act (Mont. Code Ann. §§ 39-2-901 to 39-2-915):
- Montana is the only state with a statute that replaces at-will employment with a good-cause termination standard after a probationary period
- Termination of an employee for exercising FMLA or maternity leave rights may constitute wrongful discharge

Workers' Compensation Interaction:
- If the leave is related to a work-related injury or illness, coordinate with Montana's workers' compensation system under Mont. Code Ann. Title 39, Chapter 71

12. EMPLOYEE CERTIFICATION & SIGNATURE

I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that:

• Federal FMLA leave is unpaid unless I elect (or am required) to substitute accrued paid leave
• I must provide 30 days' advance notice when the need for leave is foreseeable (29 U.S.C. § 2612(e))
• I must provide medical certification if requested by my employer
• I must make reasonable efforts to schedule foreseeable medical treatment to minimize disruption to employer operations
• Providing false or misleading information may result in denial of leave and/or disciplinary action

Employee Signature: [________________________________]
Printed Name: [________________________________]
Date: [__/__/____]

13. EMPLOYER RESPONSE

☐ APPROVED — Leave is designated as FMLA-qualifying
☐ PROVISIONALLY APPROVED — Pending receipt of medical certification
☐ DENIED — Employee does not meet eligibility requirements
☐ MORE INFORMATION NEEDED — Specify: [________________________________]

Designated Leave Period: [__/__/____] through [__/__/____]

Reason for denial (if applicable):
[________________________________]

14. SOURCES AND REFERENCES

• Family and Medical Leave Act of 1993, 29 U.S.C. §§ 2601–2654
• FMLA Regulations, 29 C.F.R. Part 825
• Montana Human Rights Act, Mont. Code Ann. Title 49, Chapter 2
• Montana Maternity Leave Protections, Mont. Code Ann. §§ 49-2-310, 49-2-311
• Montana Wrongful Discharge from Employment Act, Mont. Code Ann. §§ 39-2-901 to 39-2-915
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• Montana Human Rights Bureau: https://erd.dli.mt.gov/human-rights
• Montana Department of Labor & Industry: https://dli.mt.gov/

This document is provided for informational purposes only and does not constitute legal advice. Consult a qualified Montana attorney before use.