FMLA Leave Request Form

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JURISDICTION: NH — New Hampshire
LAST UPDATED: 2026-04-04
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FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & New Hampshire Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | N.H. Rev. Stat. Ann. § 21-I:99 et seq.)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. New Hampshire 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. New Hampshire-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. NEW HAMPSHIRE STATE LEAVE PROVISIONS

NH Paid Family & Medical Leave (N.H. Rev. Stat. Ann. § 21-I:99 et seq.):

• Voluntary insurance program — participation is optional for employers and employees
• Provides 60% wage replacement (up to the Social Security wage cap) for up to 6 weeks per year
• Maximum weekly benefit for 2026: $2,128.85
• Insurance available through MetLife (state-selected carrier)
• Covers: bonding with a new child, care for a family member with a serious health condition, employee's own serious health condition, qualifying military exigency
• Does NOT provide job protection — job protection comes from federal FMLA or other applicable law
• NH PFML benefits should run concurrently with FMLA leave when both apply

NH Parental Medical Leave (HB 1654, eff. Jan. 1, 2026):

• Employers with 20 or more employees must allow time off for medical needs related to childbirth, recovery, and care of a new baby
• Up to 25 hours of time off for pregnancy and postpartum healthcare appointments
• Applies to prenatal care, postnatal care, and related medical appointments
• Leave may be paid or unpaid depending on employer policy

Pregnancy Nondiscrimination (N.H. Rev. Stat. Ann. § 354-A:7(VI)):

• Employers with 6 or more employees may not discriminate based on pregnancy, childbirth, or related medical conditions
• Employers must treat pregnancy the same as any other temporary disability for purposes of leave and benefits

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)
☐ NH parental medical leave (HB 1654) — pregnancy/postpartum appointments

NH PFML Benefits:
☐ I intend to apply for NH PFML wage replacement benefits concurrently with this leave
☐ I do not intend to apply for NH PFML benefits
☐ Not applicable — employer does not participate in NH PFML

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)
☐ NH PFML claim filed separately with MetLife
☐ 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)

New Hampshire Protections:

• NH PFML does not independently provide job protection — job protection is provided by federal FMLA or other applicable law
• Retaliation for exercising rights under the NH parental medical leave law (HB 1654) is prohibited
• Pregnancy discrimination protections under N.H. Rev. Stat. Ann. § 354-A provide additional protections against adverse employment actions

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

NH PFML Wage Replacement (if employer participates):

Additional 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. NEW HAMPSHIRE-SPECIFIC NOTICES

NH Human Rights Commission:

• Employees who believe they have been discriminated against for exercising leave rights may file a complaint with the NH Human Rights Commission within 180 days of the alleged discriminatory act
• Contact: NH Commission for Human Rights, 2 Industrial Park Drive, Concord, NH 03301 | Phone: (603) 271-2767

NH PFML Program:

• For information about NH PFML benefits and enrollment: https://www.paidfamilymedicalleave.nh.gov/
• Claims filed through MetLife

Federal Claims:

• FMLA complaints may be filed with the U.S. Department of Labor, Wage and Hour Division
• Pregnancy discrimination claims may be filed with the EEOC within 300 days

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 or receive NH PFML benefits
• NH PFML benefits provide up to 60% wage replacement for up to 6 weeks (if enrolled)
• 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: [________________________________]

NH PFML Status: ☐ Employer participates — employee directed to file claim ☐ Employer does not participate

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
• NH Paid Family & Medical Leave, N.H. Rev. Stat. Ann. § 21-I:99 et seq.
• NH Parental Medical Leave, HB 1654 (eff. Jan. 1, 2026)
• NH Law Against Discrimination, N.H. Rev. Stat. Ann. § 354-A:7(VI)
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• NH Paid Family Medical Leave Program: https://www.paidfamilymedicalleave.nh.gov/
• NH Commission for Human Rights: https://www.nh.gov/hrc/

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