FMLA Leave Request Form - North Dakota

FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & North Dakota Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | N.D. Cent. Code § 14-02.4)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. North Dakota 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 Dakota-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 an FMLA-covered employer; private-employer coverage generally requires 50 employees for 20 workweeks in the current or preceding calendar year, while public agencies are separately covered
• Worked for the employer for at least 12 months
• 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 spouse's, child's, or parent's covered military service
• ☐ Care for a covered servicemember with a serious injury or illness (26 weeks)

4. NORTH DAKOTA STATE LEAVE PROVISIONS

No State Family or Medical Leave Act:

• N.D. Cent. Code ch. 54-52.4 covers eligible state employees, not private-sector employees
• For private-sector requests, check federal FMLA and any other applicable law, contract, collective bargaining agreement, or employer policy

State Employee FMLA Administration (N.D. Admin. Code § 4-07-38):

• The administrative chapter applies to covered state positions and implements the state employee leave chapter; state employees should identify whether federal FMLA, state leave, or both apply
• Paid leave may be available under applicable policy or agreement

State Employee Family Leave (N.D. Cent. Code § 54-52.4-02):

• Eligible state employees may request leave for the listed family and medical reasons, including the death of a child; the chapter sets separate duration, scheduling, and return-to-work rules

North Dakota Human Rights Act (N.D. Cent. Code § 14-02.4):

• Prohibits employment discrimination based on race, color, religion, sex, national origin, age, disability, marital status, and receipt of public assistance
• Sex discrimination protections include pregnancy, childbirth, and related medical conditions
• Coverage depends on the employer definition in § 14-02.4-01(8) and the facts of the employment

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)

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
• A salaried employee among the highest-paid 10% within 75 miles of the worksite may be subject to the limited restoration exception in 29 U.S.C. § 2614(b), if its other conditions are met

North Dakota Notes:

• Eligible state employees have a separate return-to-work protection under N.D. Cent. Code § 54-52.4-07, subject to its conditions and exceptions
• Termination of an employee for exercising FMLA rights may also give rise to a discrimination claim under the ND Human Rights Act if the leave is related to pregnancy or disability

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 DAKOTA-SPECIFIC NOTICES

North Dakota Department of Labor and Human Rights:

• A claim of employment discrimination based on a protected characteristic under the North Dakota Human Rights Act generally must be filed within 300 days of the alleged act under § 14-02.4-19(2); an FMLA leave dispute alone does not establish such a claim
• Contact: ND Department of Labor and Human Rights, 600 E. Boulevard Ave., Dept. 406, Bismarck, ND 58505 | Phone: (701) 328-2660

Federal Claims:

• FMLA complaints may be filed with the U.S. Department of Labor, Wage and Hour Division
• Pregnancy discrimination complaints may be cross-filed with the EEOC and the ND Department of Labor

Workers' Compensation Interaction:

• If the leave is related to a work-related injury or illness, coordinate with North Dakota Workforce Safety & Insurance (N.D. Cent. Code § 65-01 et seq.)

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
• Pay during leave depends on accrued leave, employer policy, agreement, and applicable law
• For foreseeable birth or placement leave, I generally provide 30 days' advance notice, or notice as practicable when the timing makes that impossible; planned medical treatment has separate scheduling and notice rules (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
• Fraudulently obtaining FMLA leave can remove FMLA restoration and group-health-maintenance protections under 29 C.F.R. § 825.216(d)

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

13. EMPLOYER INTAKE RECORD

☐ REQUEST RECEIVED — Employer will provide any required eligibility and designation notices separately
☐ MORE INFORMATION REQUESTED — Specify: [________________________________]
☐ REFERRED FOR REVIEW — Specify: [________________________________]

Requested leave period recorded: [__/__/____] through [__/__/____]

Follow-up or notice sent separately (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
• North Dakota Human Rights Act, N.D. Cent. Code § 14-02.4
• North Dakota State Employee Leave Policies, N.D. Cent. Code ch. 54-52.4: https://ndlegis.gov/cencode/t54c52-4.pdf
• ND State Employee FMLA, N.D. Admin. Code § 4-07-38
• ND Workforce Safety & Insurance, N.D. Cent. Code § 65-01 et seq.
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• ND Department of Labor and Human Rights: https://www.labor.nd.gov/

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