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 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 DAKOTA STATE LEAVE PROVISIONS

No State Family or Medical Leave Act:
- North Dakota 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
- North Dakota does not operate a state-funded paid family and medical leave program

State Employee FMLA Administration (N.D. Admin. Code § 4-07-38):
- North Dakota state agencies administer FMLA in accordance with federal requirements
- State employees may have additional paid leave benefits through their agency policies

New Hire Leave — State Employees (eff. May 1, 2026):
- State agencies employing individuals not under a written contract must provide new hires with 40 hours of new hire leave for use within the first year of employment
- This provision applies to state government employment only — does not extend to private employers

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
- Applies to employers with 1 or more employees

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
- Key employees (salaried, among the highest-paid 10%) may be subject to limited exceptions under 29 U.S.C. § 2614(b)

North Dakota Notes:
- North Dakota does not have a state-level job restoration requirement beyond federal FMLA
- 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:
- Employees who believe they have been discriminated against for exercising leave rights may file a complaint within 300 days of the alleged discriminatory act
- 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
• North Dakota 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
• North Dakota Human Rights Act, N.D. Cent. Code § 14-02.4
• 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.