FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & Ohio Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | Ohio Rev. Code § 4112)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Ohio 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. Ohio-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. OHIO STATE LEAVE PROVISIONS

No State Family or Medical Leave Act:
- Ohio does not have a state-level family and medical leave law for private-sector employees
- Private-sector employees rely exclusively on federal FMLA for job-protected family and medical leave
- Ohio does not operate a state-funded paid family and medical leave program

Ohio Civil Rights Act — Pregnancy Discrimination (Ohio Rev. Code § 4112.02):
- Employers with 4 or more employees may not discriminate based on pregnancy, childbirth, or related medical conditions
- Pregnancy must be treated the same as other temporary disabilities for purposes of leave and benefits
- Broader coverage than federal FMLA's 50-employee threshold
- Employers must provide reasonable accommodations for pregnancy-related conditions

State Employee Paid Parental Leave (Ohio Rev. Code § 124.136):
- Applies to state government employees only (not private sector)
- Eligible permanent full-time state employees may take up to 12 consecutive weeks of parental leave
- Up to 480 hours are paid at 70% of the employee's base rate of pay
- Available upon the birth, stillbirth, or adoption of a child
- Applies to employees paid under Ohio Rev. Code § 124.152

Ohio Military Family Leave (Ohio Rev. Code § 5906.02):
- Employees whose spouse, child, or parent is called to active duty or injured during active duty may take up to 10 days of unpaid leave per calendar year
- Applies to employers with 50 or more employees in the state

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)
☐ Ohio military family leave (Ohio Rev. Code § 5906.02)
☐ Ohio state employee paid parental leave (state employees only)

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)

Ohio Protections:
- Ohio does not have a state-level job restoration requirement beyond federal FMLA for private-sector employees
- Termination of an employee for exercising FMLA rights or pregnancy-related leave may constitute unlawful discrimination under the Ohio Civil Rights Act (Ohio Rev. Code § 4112)
- Ohio courts have recognized FMLA interference and retaliation claims in conjunction with state civil rights claims

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. OHIO-SPECIFIC NOTICES

Ohio Civil Rights Commission (OCRC):
- Employees who believe they have been discriminated against for exercising leave rights or based on pregnancy may file a complaint with the OCRC within 2 years of the alleged discriminatory act
- Contact: Ohio Civil Rights Commission, 30 E. Broad Street, 5th Floor, Columbus, OH 43215 | Phone: (614) 466-5928

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

Ohio Military Family Leave Notice:
- Employees requesting Ohio military family leave (Ohio Rev. Code § 5906.02) must provide at least 14 days' notice unless the leave is needed due to injury/hospitalization of the servicemember

Workers' Compensation Interaction:
- If the leave relates to a work-related injury or illness, coordinate with the Ohio Bureau of Workers' Compensation

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
• Ohio does not have a state paid family and medical leave program for private-sector employees
• 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: [________________________________]

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
• Ohio Civil Rights Act, Ohio Rev. Code § 4112
• Ohio State Employee Paid Parental Leave, Ohio Rev. Code § 124.136
• Ohio Military Family Leave, Ohio Rev. Code § 5906.02
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• Ohio Civil Rights Commission: https://crc.ohio.gov/
• Ohio Bureau of Workers' Compensation: https://www.bwc.ohio.gov/

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