FMLA Leave Request Form

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JURISDICTION: NE — Nebraska
LAST UPDATED: 2026-04-04
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FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & Nebraska Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | Neb. Rev. Stat. § 48-234)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Nebraska 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. Nebraska-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. NEBRASKA STATE LEAVE PROVISIONS

Pregnancy Nondiscrimination (Neb. Rev. Stat. § 48-234):

• Nebraska law prohibits discrimination based on pregnancy, childbirth, or related medical conditions
• Applies to employers with 15 or more employees
• Employers must treat pregnant employees the same as other employees with similar abilities or limitations
• Reasonable accommodations may be required for pregnancy-related conditions

Nebraska Healthy Families and Workplaces Act (Initiative 436, eff. Oct. 1, 2025):

• Employers with 1–10 employees: up to 40 hours of paid sick leave per year
• Employers with 11–19 employees: up to 40 hours of paid sick leave per year
• Employers with 20+ employees: up to 56 hours of paid sick leave per year
• Accrual rate: 1 hour for every 30 hours worked
• May be used for employee's or family member's illness, injury, medical care, or preventive care
• May also be used for domestic violence, sexual assault, or stalking-related absences

No State Paid Family & Medical Leave:

• Nebraska does not currently operate a state-funded paid family and medical leave program
• All FMLA leave in Nebraska is unpaid unless the employee elects (or employer requires) use of accrued paid leave

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)

Nebraska Protections:

• Termination or demotion of an employee for exercising FMLA rights or pregnancy-related leave may constitute unlawful discrimination under the Nebraska Fair Employment Practice Act (Neb. Rev. Stat. §§ 48-1101 to 48-1126)
• Retaliation for use of paid sick leave under the Healthy Families and Workplaces Act is prohibited

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. NEBRASKA-SPECIFIC NOTICES

Nebraska Equal Opportunity Commission (NEOC):

• Employees who believe they have been discriminated against for exercising leave rights may file a complaint with the NEOC within 300 days of the alleged discriminatory act
• Contact: Nebraska Equal Opportunity Commission, 301 Centennial Mall South, 5th Floor, Lincoln, NE 68509 | Phone: (402) 471-2024

Filing with EEOC:

• Federal 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 NEOC

Nebraska Paid Sick Leave Posting:

• Employers must display workplace postings informing employees of their rights under the Healthy Families and Workplaces Act

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
• Nebraska Fair Employment Practice Act, Neb. Rev. Stat. §§ 48-1101 to 48-1126
• Nebraska Pregnancy Nondiscrimination, Neb. Rev. Stat. § 48-234
• Nebraska Healthy Families and Workplaces Act (Initiative 436, eff. Oct. 1, 2025)
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• Nebraska Equal Opportunity Commission: https://neoc.nebraska.gov/

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