FMLA Leave Request Form

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JURISDICTION: OK — Oklahoma
LAST UPDATED: 2026-04-04
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FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & Oklahoma Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | Okla. Stat. tit. 25, § 1301 et seq.)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Oklahoma 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. Oklahoma-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. OKLAHOMA STATE LEAVE PROVISIONS

No State Family or Medical Leave Act:

• Oklahoma does not have a state-level family and medical leave law
• Private-sector employees rely exclusively on federal FMLA for job-protected family and medical leave
• Oklahoma does not operate a state-funded paid family and medical leave program

Oklahoma Anti-Discrimination Act (Okla. Stat. tit. 25, § 1301 et seq.):

• Employers with 15 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

Employer Tax Credit for Voluntary Paid Family Leave (HB 2260, eff. Jan. 1, 2026):

• Oklahoma offers a state income tax credit for employers that voluntarily provide paid family leave to employees
• Available for tax years January 1, 2026 through December 31, 2030
• Encourages employer-provided paid leave but does not mandate it
• Employees should check whether their employer participates in this voluntary program

Military Leave (Okla. Stat. tit. 44, § 208.1):

• Employees called to active military duty are entitled to reinstatement upon return
• State and local government employees receive up to 30 days of paid military leave per federal fiscal year

Voting Leave (Okla. Stat. tit. 26, § 7-101):

• Employees entitled to 2 hours of paid leave to vote on election days (limited applicability to FMLA context)

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)

Employer Voluntary Paid Family Leave:
☐ My employer provides voluntary paid family leave — I intend to use it concurrently
☐ My employer does not provide voluntary paid family leave
☐ Unknown — will inquire with HR

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)

Oklahoma Notes:

• Oklahoma does not have a state-level job restoration requirement beyond federal FMLA
• Termination of an employee for exercising FMLA rights or pregnancy-related leave may constitute unlawful discrimination under the Oklahoma Anti-Discrimination Act
• Oklahoma is an at-will employment state, but FMLA and anti-discrimination protections still apply

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 employer-provided voluntary paid family leave (if available)
☐ I understand the employer may require substitution of accrued paid leave

11. OKLAHOMA-SPECIFIC NOTICES

Oklahoma Human Rights Commission (OHRC):

• Employees who believe they have been discriminated against for exercising leave rights or based on pregnancy may file a complaint with the OHRC within 180 days of the alleged discriminatory act
• Contact: Oklahoma Human Rights Commission, 2101 N. Lincoln Blvd., Suite 480, Oklahoma City, OK 73105 | Phone: (405) 521-2360

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 (cross-filed with OHRC)

HB 2260 — Employer Tax Credit:

• Oklahoma employers that voluntarily provide paid family leave may be eligible for a state income tax credit (eff. Jan. 1, 2026 through Dec. 31, 2030)
• Employees may wish to inquire whether their employer participates in this program

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
• Oklahoma does not mandate paid family and medical leave (some employers may provide it voluntarily)
• 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: [________________________________]

Employer Voluntary Paid Family Leave: ☐ Available ☐ Not available

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
• Oklahoma Anti-Discrimination Act, Okla. Stat. tit. 25, § 1301 et seq.
• Oklahoma Military Leave, Okla. Stat. tit. 44, § 208.1
• Employer Tax Credit for Paid Family Leave, HB 2260 (eff. Jan. 1, 2026)
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• Oklahoma Human Rights Commission: https://www.ok.gov/ohrc/

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