FMLA Leave Request Form - Nevada

FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & Nevada Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | Nev. Rev. Stat. §§ 608.0197, 629.0625)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Nevada 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. Nevada-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. NEVADA STATE LEAVE PROVISIONS

Nevada Paid Leave (Nev. Rev. Stat. § 608.0197 — SB 312, eff. Jan. 1, 2020):

• The law covers private employers with 50 or more employees in Nevada, subject to its exclusions
• An employer is exempt during its first 2 years of operation
• Temporary, seasonal, and on-call employees are excluded; an equivalent or more generous paid-leave/PTO policy may satisfy the statute
• Accrual: 0.01923 hours of paid leave for every hour worked
• An employer may limit use and carryover to 40 hours per benefit year
• Available leave may be used beginning on the 90th calendar day of employment for any reason without stating the reason; notice is due as soon as practicable

FMLA Certification Form Charge (Nev. Rev. Stat. § 629.0625):

• The statute sets a $30 base amount for a health care provider to fill out a certification form required under 29 U.S.C. § 2613
• The base amount must be increased or decreased annually based on the Consumer Price Index (All Items) for the immediately preceding year
• The Nevada Department of Human Services must establish and post the adjusted amount that takes effect each January 1; confirm the Department's current posted amount rather than treating $30 as a fixed current cap

Pregnancy Accommodation (Nev. Rev. Stat. §§ 613.4353 to 613.4383):

• Employers with 15 or more employees must provide reasonable accommodations for conditions related to pregnancy, childbirth, or related medical conditions
• Accommodations may include transfer to a less strenuous position, modified work schedules, or additional break time
• Employers may not require a pregnant employee to take leave if a reasonable accommodation can be provided

Domestic Violence and Sexual Assault Leave (Nev. Rev. Stat. § 608.0198):

• After 90 days of employment, an eligible employee may take up to 160 hours of paid or unpaid leave per 12-month period for qualifying domestic-violence or sexual-assault purposes, used within 12 months after the act

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

NEVADA CHARGE INFORMATION: Nev. Rev. Stat. § 629.0625 sets a $30 statutory base amount for completion of an FMLA certification form, adjusted each January 1. Confirm the current maximum posted by the Nevada Department of Human Services before payment; this form does not state a fixed current charge.

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)

Nevada Protections:

• Termination or adverse action against an employee for exercising FMLA or pregnancy accommodation rights may violate Nev. Rev. Stat. §§ 613.4353 to 613.4383 and federal law
• Retaliation for use of Nevada paid leave (NRS § 608.0197) 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 elect to use Nevada paid leave (NRS § 608.0197) concurrently with FMLA leave
☐ I understand the employer may require substitution of accrued paid leave

11. NEVADA-SPECIFIC NOTICES

Nevada Equal Rights Commission (NERC):

• Employees who believe they have been discriminated against or retaliated against for exercising leave rights may file a complaint with NERC within 300 days of the alleged discriminatory act
• Contact: Nevada Equal Rights Commission, 1820 E. Sahara Ave., Suite 314, Las Vegas, NV 89104 | Phone: (702) 486-7161

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 (cross-filed with NERC)

NRS 629.0625 — FMLA Certification Form Charge:

• This section regulates the health care provider's charge; it does not require an employer to give a fee-cap notice. If the employer provides this information voluntarily, confirm and state the Department's current adjusted amount.

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
• Nevada law limits the provider's FMLA-certification charge under NRS 629.0625, subject to the Department's annual adjustment
• 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
• Nevada Paid Leave, Nev. Rev. Stat. § 608.0197 (SB 312)
• Nevada Pregnant Workers' Fairness Act, Nev. Rev. Stat. §§ 613.4353 to 613.4383
• Nevada Domestic Violence Leave, Nev. Rev. Stat. § 608.0198
• Nevada FMLA Certification Form Charge, Nev. Rev. Stat. § 629.0625 (enacted by Assembly Bill 305 (2025))
• Nevada Department of Human Services, current FMLA certification-charge table: https://www.dpbh.nv.gov/resources/family-and-medical-leave-acts-fmla/
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• Nevada Equal Rights Commission: https://detr.nv.gov/NERC

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