FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & New Mexico Paid Family & Medical Leave

(29 U.S.C. §§ 2601 et seq. | NM PFMLA)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. New Mexico 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 Mexico-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 MEXICO STATE LEAVE PROVISIONS

A. New Mexico Paid Family & Medical Leave Act (PFMLA)

Program Overview:
- State-administered paid family and medical leave program
- Administered by the NM Department of Workforce Solutions
- Provides up to 12 weeks of paid leave per year

Covered Reasons:
- Employee's own serious health condition
- Care for a family member with a serious health condition
- Bonding with a new child (birth, adoption, or foster placement)
- Military qualifying exigency

Contribution Structure (eff. Jan. 1, 2025):
- Employees: 0.5% of earnings
- Employers with 5+ employees: 0.4% of each employee's earnings
- Employers with fewer than 5 employees: Not required to contribute (employees still contribute)
- Self-employed individuals: 0.5% of net income (voluntary)

Benefits:
- Partial wage replacement for up to 12 weeks
- Benefit amount determined by the Department of Workforce Solutions
- Benefits may run concurrently with federal FMLA leave

B. New Mexico Human Rights Act — Pregnancy (N.M. Stat. Ann. § 28-1-7)

• Employers with 4 or more employees may not discriminate based on pregnancy, childbirth, or related conditions
• Employers must provide reasonable accommodations for pregnancy-related conditions
• Broader coverage than federal FMLA's 50-employee threshold

C. Healthy Workplaces Act (N.M. Stat. Ann. § 50-17-1 et seq.)

• All employers must provide 1 hour of paid sick leave for every 30 hours worked
• Up to 64 hours per year
• May be used for the employee's or a family member's health condition, preventive care, or domestic abuse-related needs

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)

NM PFMLA Benefits:
☐ I intend to apply for NM PFMLA wage replacement benefits concurrently with this leave
☐ I do not intend to apply for NM PFMLA benefits at this time

Name of family member (if applicable): [________________________________]
Relationship to employee: [________________________________]

Brief description of reason for leave:
[________________________________]
[________________________________]

6. LEAVE SCHEDULE

Federal FMLA Tracking:

NM PFMLA 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)
☐ NM PFMLA claim filed separately with NM Department of Workforce Solutions
☐ 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

New Mexico Protections:
- The NM Human Rights Act (N.M. Stat. Ann. § 28-1-7) prohibits retaliation for asserting rights related to pregnancy or disability accommodation
- Retaliation for filing a NM PFMLA claim or exercising leave rights is prohibited
- Employees who believe they have been retaliated against may file a complaint with the NM Human Rights Bureau

10. BENEFITS DURING LEAVE

Health Insurance Continuation:
- FMLA: Employer must maintain group health insurance under the same terms (29 U.S.C. § 2614(c))
- Employee must continue to pay their share of premiums

NM PFMLA Wage Replacement:

Additional Paid Leave Substitution:

☐ I elect to substitute accrued paid leave concurrently with FMLA leave
☐ I intend to use NM Healthy Workplaces Act paid sick leave concurrently
☐ I understand the employer may require substitution of accrued paid leave

11. NEW MEXICO-SPECIFIC NOTICES

NM Human Rights Bureau:
- Employees who believe they have been discriminated against or retaliated against for exercising leave rights may file a complaint within 300 days of the alleged discriminatory act
- Contact: NM Human Rights Bureau, 1596 Pacheco Street, Suite 103, Santa Fe, NM 87505 | Phone: (505) 827-6838

NM Department of Workforce Solutions — PFMLA:
- For PFMLA claims, benefits information, and enrollment: https://www.dws.state.nm.us/PFML
- Also: https://nmpfml.org/

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

Healthy Workplaces Act Posting:
- Employers must display workplace postings informing employees of their rights under the Healthy 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 or receive NM PFMLA benefits
• NM PFMLA provides up to 12 weeks of paid leave benefits per year
• 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: [________________________________]

NM PFMLA Status: ☐ Employee directed to file PFMLA claim ☐ Not applicable

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
• New Mexico Paid Family & Medical Leave Act (PFMLA, eff. 2025)
• New Mexico Human Rights Act, N.M. Stat. Ann. § 28-1-7
• New Mexico Healthy Workplaces Act, N.M. Stat. Ann. § 50-17-1 et seq.
• N.M. Admin. Code § 1.7.7.12 (State Employee FMLA)
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• NM Department of Workforce Solutions PFML: https://www.dws.state.nm.us/PFML
• NM Paid Family & Medical Leave: https://nmpfml.org/
• NM Human Rights Bureau: https://www.dws.state.nm.us/

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