FMLA Leave Request Form - New Mexico

FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA Request and New Mexico Leave Coordination

(29 U.S.C. §§ 2611–2614 | NMSA 1978 §§ 28-1-7 and 50-17-1 through 50-17-12)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. New Mexico Coordination
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 Mexico-Specific Notices
12. Employee Certification & Signature
13. Employer Response
14. Sources and References

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. FEDERAL FMLA OVERVIEW

Employee Eligibility Requirements (29 U.S.C. § 2611(2); 29 C.F.R. § 825.110):

• Employer is covered under the FMLA; employer coverage is a separate determination
• Worked for the employer for at least 12 months (the months need not always be consecutive; apply the break-in-service rules in § 825.110(b))
• 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

Special rules apply to public agencies, schools, airline flight crews, breaks in service, and some remote or mobile employees. HR must make the coverage and eligibility determinations rather than asking the employee to certify them.

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)):

• ☐ 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 MEXICO COORDINATION

A. No Enacted Statewide PFML Benefit Program

New Mexico did not enact the contribution-funded paid family and medical leave program described in the former version of this form. The Legislature's official page shows 2025 HB 11 died after action was postponed indefinitely. Do not collect a supposed PFML contribution, promise a PFML wage-replacement benefit, or direct an employee to a nonexistent PFML claim portal.

B. Human Rights Act — Pregnancy and Childbirth

NMSA 1978 § 28-1-7(A), (K), and (L) prohibits covered employment discrimination because of pregnancy, childbirth, or a related condition; requires reasonable accommodation for a related need; and prohibits requiring paid or unpaid leave when another reasonable accommodation can be provided, unless the employee voluntarily requests leave or is placed on leave under federal law. Coverage and accommodation analysis are separate from FMLA eligibility.

Accommodation requested, if any: [________________________________]

C. Healthy Workplaces Act Earned Sick Leave

For an employee and employer covered by NMSA 1978 § 50-17-2:

• Leave accrues at least one hour per thirty hours worked, or the employer may use the statutory frontload option; use may be limited to sixty-four hours in a twelve-month period unless the employer selects a higher limit (§ 50-17-3(A)).
• Covered uses include the employee's or a family member's health needs and preventive care, a child's health/disability school meeting, and specified domestic-abuse, sexual-assault, or stalking needs (§ 50-17-3(C)).
• The request may be oral or written. Foreseeable use requires reasonable advance effort; unforeseeable use requires notice as soon as practicable (§ 50-17-3(D)-(E)).
• Documentation generally may be required only after two or more consecutive workdays, and protected information is confidential subject to the statutory exceptions (§ 50-17-5).
• Retaliation and counting protected sick leave in a way that leads to adverse action are prohibited (§ 50-17-8).

Earned sick leave requested: ☐ No ☐ Yes — [____] hours from [__/__/____] through [__/__/____]

5. TYPE OF LEAVE REQUESTED

Select all that apply:

Federal FMLA Qualifying Reasons:
☐ 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 sufficient to identify the possible leave reason and anticipated timing/duration (do not include a diagnosis here):
[________________________________]
[________________________________]

6. LEAVE SCHEDULE

Federal FMLA Tracking:

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

Use the current DOL certification form or another complete and sufficient certification. Do not request medical information beyond what the FMLA permits.

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

New Mexico Coordination:

• Section 28-1-7 prohibits pregnancy/childbirth discrimination and requires the accommodations described in Section 4 above.
• Section 50-17-8 protects exercise of Healthy Workplaces Act rights.
• This form makes no representation that either state law supplies the same job-restoration entitlement as federal FMLA.

10. BENEFITS DURING LEAVE

Health Insurance Continuation:

• FMLA: Employer must maintain group health insurance under the same terms (29 U.S.C. § 2614(c))
• The employer's rights-and-responsibilities notice must explain any employee premium-payment requirement and arrangements (29 C.F.R. § 825.300(c))

Additional Paid Leave Substitution:

☐ I elect to substitute accrued paid leave concurrently with FMLA leave
☐ I request available New Mexico Healthy Workplaces Act earned sick leave for qualifying time
☐ I understand the employer may require substitution of accrued paid leave only as federal law and the applicable policy permit; New Mexico earned sick leave remains subject to the Healthy Workplaces Act

11. NEW MEXICO-SPECIFIC NOTICES

Pregnancy accommodation: Do not treat leave as the only accommodation. Record the interactive review of the employee's requested accommodation and the alternatives considered under § 28-1-7(K)-(L): [________________________________].

Healthy Workplaces Act: The employer may not require the employee to find a replacement worker, may not delay commencement solely because documentation has not yet arrived, and must protect the confidentiality of the information as § 50-17-5 requires.

Federal employer notice: This intake form does not replace the eligibility, rights-and-responsibilities, or designation notices required by 29 C.F.R. § 825.300.

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 generally is unpaid; any substitution of accrued paid leave is governed by 29 U.S.C. § 2612(d), 29 C.F.R. § 825.207, and the applicable paid-leave policy
• I should provide at least 30 days' advance notice when the need is foreseeable and 30 days is practicable; otherwise I should give notice as soon as practicable (29 C.F.R. §§ 825.302–825.303)
• If my employer properly requests certification, I should return a complete and sufficient certification within the stated deadline or promptly explain why diligent, good-faith efforts cannot meet it (29 C.F.R. § 825.305)
• I must make reasonable efforts to schedule foreseeable medical treatment to minimize disruption

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

13. EMPLOYER RESPONSE

This internal response does not replace DOL notices. When the request may qualify, provide the eligibility and rights-and-responsibilities notice within the time required by 29 C.F.R. § 825.300 and separately provide a designation notice.

☐ ELIGIBLE — Send required notices and evaluate certification/designation
☐ NOT ELIGIBLE — State at least one reason in the required eligibility notice
☐ MORE INFORMATION NEEDED — Specify: [________________________________]

Designated Leave Period: [__/__/____] through [__/__/____]

Reason for denial (if applicable):
[________________________________]

14. SOURCES AND REFERENCES

• GPO, 29 U.S.C. §§ 2611–2614: https://www.govinfo.gov/app/collection/uscode/2024/title29
• eCFR, current 29 C.F.R. Part 825: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-V/subchapter-C/part-825
• New Mexico Compilation Commission, current Chapter 28 (§ 28-1-7): https://nmonesource.com/nmos/nmsa/en/4365/1/document.do
• New Mexico Compilation Commission, current Chapter 50 (Healthy Workplaces Act): https://nmonesource.com/nmos/nmsa/en/4420/1/document.do
• New Mexico Legislature, 2025 HB 11 (official status: died/action postponed indefinitely): https://www.nmlegis.gov/Legislation/Legislation?chamber=H&legType=B&legNo=11&year=25
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms

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