FMLA Leave Request Form - Oregon

FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA, Oregon Family Leave Act & Paid Leave Oregon

Federal FMLA, Oregon Family Leave Act, and Paid Leave Oregon Screening Packet

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Oregon 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. Oregon-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)):

• 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
• Airline flight crew employees use the special federal hours-of-service rule

Covered Employer:

• A private-sector employer generally must have 50 or more employees for 20 or more workweeks in the current or preceding calendar year
• Public agencies and covered local educational agencies have separate coverage rules regardless of headcount

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)

Notice and Certification: Give at least 30 days' notice when the need is foreseeable; otherwise give notice as soon as practicable. If the employer properly requests certification, the usual federal response period is 15 calendar days, subject to the regulation's practicability exception.

4. OREGON STATE LEAVE PROVISIONS

A. Oregon Family Leave Act (OFLA) — Current Oregon Framework

Employer Coverage:

• Generally, 25 or more employees in Oregon for each working day during 20 or more workweeks in the current or preceding year

Employee Eligibility:

• Generally, at least 180 days with the employer and an average of at least 25 hours per week during the preceding 180 days
• During a covered public health emergency, the statute generally uses 30 days of employment and a 25-hour weekly average during that period
• Oregon-based airline flight crew employees have a special incorporated federal hours-of-service route

Leave Entitlement:

• Up to 12 weeks in the OFLA year for sick-child and bereavement leave combined
• Bereavement is limited to 2 weeks per family-member death, no more than 4 weeks total in the OFLA year, and must be completed within 60 days after notice of the death
• Up to 12 additional weeks for an illness, injury or condition related to the employee's own pregnancy or childbirth that disables the employee from performing available job duties

Current Qualifying Reasons:

• ☐ Sick-child leave for the employee's child who needs home care because of illness, injury or condition
• ☐ Sick-child leave for a qualifying school or child-care closure during a public health emergency
• ☐ Bereavement following the death of a family member
• ☐ Pregnancy-disability leave for the employee's own pregnancy- or childbirth-related incapacity or prenatal care

Important: Current OFLA does not supply the old general banks for bonding, the employee's ordinary serious health condition, or care of an adult family member with a serious health condition. Those events may instead qualify under Paid Leave Oregon, federal FMLA, another law, or employer policy.

B. Paid Leave Oregon (PLO) — Current Oregon Framework

Coverage:

• The statutory employer definition generally reaches a person employing one or more employees working in Oregon; federal and tribal governments are excluded from that definition
• The state plan and approved equivalent plans use separate claim procedures

Benefit Eligibility:

• Generally, at least $1,000 in wages in the base year or alternate base year
• The employee must satisfy the contribution and claim requirements in ORS 657B.015
• Eligibility for wage-replacement benefits is distinct from the 90-day employment requirement for statutory job protection

Benefits:

• Up to 12 weeks of paid leave per benefit year
• Up to 2 additional weeks for limitations related to pregnancy, childbirth or a related medical condition, including lactation (14 weeks maximum)
• The weekly formula pays 100% of the employee's average weekly wage up to 65% of the state average weekly wage, then adds 50% of the employee wage above that point, subject to the statutory minimum and maximum

Qualifying Reasons:

• Family leave: bonding during the first year after birth, foster placement or adoption; required pre-placement activities; or care for a family member with a serious health condition
• Medical leave: the employee's own serious health condition
• Safe leave: a purpose incorporated from Oregon's protected safe-leave law

Coordination:

• Paid Leave Oregon family or medical leave must run concurrently with federal FMLA leave for the same purpose
• OFLA may not run concurrently with Paid Leave Oregon leave
• Paid Leave Oregon benefits are administered by OED or an approved equivalent plan; filing this employer notice does not submit the benefit claim

5. TYPE OF LEAVE REQUESTED

Select all that apply:

Federal FMLA:
☐ 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
☐ Employee's own serious health condition
☐ Care for spouse/child/parent with a serious health condition
☐ Qualifying exigency — military deployment
☐ Military caregiver leave (26-week entitlement)

OFLA:
☐ Sick-child leave — illness, injury or condition requiring home care
☐ Sick-child leave — school or child-care closure during a public health emergency
☐ Bereavement leave
☐ Pregnancy-disability leave (separate additional bank)

Paid Leave Oregon:
☐ Family leave — bonding with new child
☐ Family leave — care for family member with serious health condition
☐ Medical leave — own serious health condition
☐ Safe leave — qualifying purpose under current Oregon safe-leave law

Program requested: ☐ Employer to evaluate all applicable programs ☐ FMLA only ☐ OFLA only ☐ Paid Leave Oregon notice plus separate benefit claim

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

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

6. LEAVE SCHEDULE

Federal FMLA Tracking:

OFLA Tracking:

Paid Leave Oregon 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:

Increment requested: [____] hours / [____] full workdays. Paid Leave Oregon benefits are generally claimed in full-day or full-week increments; FMLA and OFLA increment rules differ and must be evaluated separately.

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)
☐ PLO claim filed with Oregon Employment Department
☐ PLO claim filed with employer's approved equivalent plan
☐ No medical certification required for this leave type

Certification timing and limits:

• FMLA: if the employer requests certification, the employee ordinarily has 15 calendar days, unless timely completion is not practicable despite diligent, good-faith efforts
• OFLA pregnancy-disability leave may be medically verified; sick-child verification generally may be requested only after more than three days of OFLA sick-child leave in the OFLA year, and the employer bears the verification cost and may not require a second opinion
• Paid Leave Oregon supporting documents go to OED or the approved equivalent plan under that claim process; do not attach medical records to this employer form unless the applicable law and employer procedure require them

Certifying Healthcare Provider:

9. JOB RESTORATION RIGHTS

Federal FMLA Restoration (29 U.S.C. § 2614(a)):

• An eligible employee generally is entitled to the same position or an equivalent position with equivalent pay, benefits, and working conditions, subject to the statute's limited restoration rules, including the highly compensated key-employee provision

OFLA Restoration (ORS § 659A.171):

• Employee is entitled to the former position if it still exists; otherwise, to an available equivalent position under the statute's job-site sequence, including an available site within 50 miles when required

Paid Leave Oregon Job Protection (ORS § 657B.060):

• Statutory job protection applies to an eligible employee employed by the employer for at least 90 days before leave
• If the former position no longer exists, the restoration rule differs for employers with fewer than 25 employees; the employer must apply ORS 657B.060 to the actual headcount and available positions

10. BENEFITS DURING LEAVE

Health Insurance Continuation:

• FMLA, OFLA and Paid Leave Oregon each contain health-benefit continuation rules for protected leave; the employee generally must continue regular premium contributions
• Employee must continue to pay their share of premiums

Paid Leave Oregon Wage Replacement:

Additional Paid Leave Substitution:

☐ I elect to use accrued paid leave during unpaid FMLA/OFLA leave to the extent permitted by law and policy
☐ I understand the employer may require or order use of accrued paid leave only to the extent allowed by the applicable statute, agreement and policy
☐ I request to use accrued paid leave in addition to Paid Leave Oregon benefits, subject to the full-wage-replacement limit unless the employer permits more under ORS 657B.030(2)(b)

11. OREGON-SPECIFIC NOTICES

Oregon Bureau of Labor and Industries (BOLI):

• OFLA rights and complaint information: https://www.oregon.gov/boli/workers/pages/oregon-family-leave.aspx
• Paid Leave Oregon job-protection or retaliation issues may be raised through the current statutory remedy route; verify the current filing deadline and forum from the challenged action and agency instructions

Oregon Employment Department (OED):

• Paid Leave Oregon benefit claims: Frances Online or the current paper process at https://paidleave.oregon.gov/employees/overview.html
• Phone: (833) 854-0166

Federal Claims:

• FMLA complaints: U.S. Department of Labor, Wage and Hour Division

OFLA vs. PLO vs. FMLA — Key Distinctions:
| Feature | FMLA | OFLA | Paid Leave Oregon |
|---------|------|------|-------------------|
| Employer coverage | Private-sector 50+; public/school rules differ | 25+ in Oregon | Generally 1+ Oregon employee; statutory exclusions apply |
| Employee eligibility | 12 mo / 1,250 hrs | 180 days / 25 hrs/wk | $1,000 in base year |
| Core reasons | Bonding; specified serious health conditions; military family leave | Sick child; bereavement; pregnancy disability | Family; medical; safe leave |
| Duration | 12 weeks (26 military caregiver) | 12 weeks sick child/bereavement + 12 pregnancy disability | 12 weeks (+2 pregnancy-related) |
| Paid | No | No | Yes |
| Job protection | Yes | Yes | Yes (90+ days) |

The chart is a screening aid. Public-employer, school, airline-flight-crew, public-health-emergency, equivalent-plan and other special rules require separate review.

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 substitute accrued paid leave or receive PLO benefits
• Current OFLA is limited to sick-child leave, bereavement and a separate pregnancy-disability bank; it is not a general bonding or serious-health-condition program
• Paid Leave Oregon provides up to 12 weeks of paid benefits (plus 2 additional weeks for pregnancy)
• OFLA and federal FMLA run concurrently when the same event qualifies under both; Paid Leave Oregon family or medical leave runs concurrently with federal FMLA for the same purpose; OFLA and Paid Leave Oregon do not run concurrently
• The programs use different notice rules; I will give 30 days' notice when required for foreseeable leave and otherwise give the applicable prompt oral and written notices
• I must provide medical certification if requested
• Paid Leave Oregon benefits require a separate claim through OED or the approved equivalent plan

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

13. EMPLOYER RESPONSE

☐ FMLA ELIGIBILITY/DESIGNATION NOTICE ISSUED — Date: [__/__/____]
☐ OFLA ELIGIBILITY/DESIGNATION NOTICE ISSUED — Date: [__/__/____]
☐ OFLA PROVISIONALLY DESIGNATED — Pending verification or Paid Leave Oregon claim decision
☐ PAID LEAVE OREGON EMPLOYER NOTICE RECORDED — Benefit eligibility will be decided by OED or the approved equivalent plan
☐ MORE INFORMATION NEEDED — Specify the program, information, deadline and legal basis: [________________________________]
☐ NOT ELIGIBLE / NOT DESIGNATED — Attach the program-specific written explanation and required notices

Leave Designation:
☐ Federal FMLA ☐ OFLA Pregnancy Disability ☐ OFLA Sick Child ☐ OFLA Bereavement ☐ Paid Leave Oregon notice only

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

Reason for denial (if applicable):
[________________________________]

14. SOURCES AND REFERENCES

• Federal FMLA, 29 U.S.C. §§ 2611, 2612 and 2614: https://www.govinfo.gov/app/collection/uscode/2024/title29
• Current FMLA regulations: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-V/subchapter-C/part-825
• Oregon Family Leave Act: https://www.oregonlegislature.gov/bills_laws/ors/ors659A.html
• Paid Leave Oregon statutes: https://www.oregonlegislature.gov/bills_laws/ors/ors657B.html
• 2026 SB 1507 enrolled text: https://olis.oregonlegislature.gov/liz/2026R1/Downloads/MeasureDocument/SB1507/Enrolled
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• BOLI — Oregon Family Leave: https://www.oregon.gov/boli/workers/pages/oregon-family-leave.aspx
• Paid Leave Oregon employee overview and claim routes: https://paidleave.oregon.gov/employees/overview.html

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