FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & North Carolina Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | N.C. Gen. Stat. Chapter 95)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. North Carolina 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. North Carolina-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. NORTH CAROLINA STATE LEAVE PROVISIONS

No State Family or Medical Leave Act:
- North Carolina does not have a state-level family and medical leave law for private-sector employees
- Private-sector employees rely exclusively on federal FMLA for job-protected family and medical leave

State Employee Paid Parental Leave (N.C. Gen. Stat. § 126-8.6):
- Applies to state government employees only (not private sector)
- Provides paid parental leave for state employees upon the birth or adoption of a child
- Must be used within 12 months of the qualifying event

Lactation Accommodation (N.C. Gen. Stat. § 95-28.3):
- Employers must provide reasonable break time and a private location (other than a restroom) for nursing mothers to express breast milk for up to one year after the birth of a child

Domestic Violence Leave — Public Employees (N.C. Gen. Stat. § 143-166.14):
- State employees may use sick leave for domestic violence-related purposes

NC Equal Employment Practices Act (N.C. Gen. Stat. § 143-422.2):
- Prohibits discrimination based on race, religion, color, national origin, age, sex, or disability
- Enforced by the NC Human Relations Commission, though the Act has limited enforcement mechanisms compared to federal law

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)
☐ NC state employee paid parental leave (state employees only)

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)

North Carolina Notes:
- North Carolina does not have a state-level job restoration requirement beyond federal FMLA
- Private-sector employees rely exclusively on federal FMLA for job restoration rights
- Retaliation claims may also be brought under the NC Retaliatory Employment Discrimination Act (N.C. Gen. Stat. § 95-241) for employees who file workers' compensation claims or exercise other protected rights

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. NORTH CAROLINA-SPECIFIC NOTICES

Filing Complaints:
- Federal FMLA: File with the U.S. Department of Labor, Wage and Hour Division, Charlotte District Office or Raleigh Area Office
- Pregnancy/Sex Discrimination: File with the EEOC within 180 days (or 300 days if cross-filed with a state agency)
- NC Human Relations Commission: Although NC has limited state enforcement, complaints may be filed for investigation

NC Department of Labor:
- Contact: NC Department of Labor, 4 West Edenton Street, Raleigh, NC 27601 | Phone: (919) 707-7900
- Website: https://www.labor.nc.gov/

Pending Legislation:
- The NC Paid Family Leave Insurance Act (SB 480/HB 499, 2025-2026 session) has been introduced but not enacted as of April 2026
- Check current legislative status for updates

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
• North Carolina does not have a state paid family and medical leave program
• 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
• 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
• NC State Employee Paid Parental Leave, N.C. Gen. Stat. § 126-8.6
• NC Lactation Accommodation, N.C. Gen. Stat. § 95-28.3
• NC Equal Employment Practices Act, N.C. Gen. Stat. § 143-422.2
• NC Retaliatory Employment Discrimination Act, N.C. Gen. Stat. § 95-241
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• NC Department of Labor: https://www.labor.nc.gov/

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