FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA, Oregon Family Leave Act & Paid Leave Oregon

(29 U.S.C. §§ 2601 et seq. | ORS §§ 659A.150–186 | ORS §§ 657B.010–990)

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)):
- 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. OREGON STATE LEAVE PROVISIONS

A. Oregon Family Leave Act (OFLA) — ORS §§ 659A.150–659A.186

Employer Coverage:
- Employers with 25 or more employees in Oregon

Employee Eligibility:
- Worked for employer for at least 180 days
- Averaged at least 25 hours per week during those 180 days
- Exception: During a public health emergency, eligible with 30 days of employment

Leave Entitlement:
- Up to 12 weeks per leave year for most qualifying reasons
- Up to 12 additional weeks for pregnancy disability leave (total 24 weeks)
- Bereavement: up to 2 weeks per family member death, max 4 weeks per leave year

Qualifying Reasons:
- ☐ Employee's own serious health condition
- ☐ Care for a family member with a serious health condition (broader family definition than FMLA)
- ☐ Bonding with a new child (birth, adoption, foster placement)
- ☐ Pregnancy disability
- ☐ Sick child leave (non-serious conditions, school/childcare closures)
- ☐ Bereavement leave (death of a family member)

OFLA Family Member Definition (broader than FMLA):
- Spouse, domestic partner, child, parent, parent-in-law, grandparent, grandchild, and any individual related by blood or affinity whose close association is the equivalent of a family relationship

B. Paid Leave Oregon (PLO) — ORS §§ 657B.010–657B.990

Coverage:
- Applies to all Oregon employers (no minimum employee threshold for coverage)
- Contributions required from all employers and employees

Employee Eligibility:
- Earned at least $1,000 in wages during the base year
- Currently employed or employed within the past 12 months

Benefits:
- Up to 12 weeks of paid leave per benefit year
- Up to 2 additional weeks for pregnancy-related conditions (total 14 weeks)
- Wage replacement: 100% of average weekly wage up to 65% of the state average weekly wage, then 50% of wages above that threshold (subject to a cap)
- Maximum weekly benefit determined annually by OED

Contribution Rate (2025/2026):
- Total rate: 1% of employee's gross earnings per pay period
- Split: 60% employee / 40% employer (employers with fewer than 25 employees are not required to pay the employer portion)

Qualifying Reasons:
- Family leave (bonding, care for family member)
- Medical leave (own serious health condition)
- Safe leave (domestic violence, sexual assault, stalking, harassment)

Coordination with OFLA:
- PLO and OFLA do not run concurrently for the same leave period
- PLO does not cover leave for less than a full day; OFLA does
- Starting January 1, 2026, BOLI oversees enforcement of PLO job protection and anti-retaliation

C. Oregon Sick Time (ORS § 653.601 et seq.)

• Employers with 10+ employees (6+ in Portland): 40 hours of paid sick time per year
• Employers with fewer than 10 employees: 40 hours of unpaid protected sick time per year
• Accrual: 1 hour per 30 hours worked

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:
☐ Employee's own serious health condition
☐ Care for family member with a serious health condition
☐ Bonding with new child
☐ Pregnancy disability (additional 12 weeks)
☐ Sick child leave (non-serious condition, school/childcare closure)
☐ Bereavement leave

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 — domestic violence, sexual assault, stalking, or harassment

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:

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

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

OFLA Restoration (ORS § 659A.171):
- Employee is entitled to be restored to the position held before OFLA leave began, or to an equivalent position
- No "key employee" exception under OFLA

Paid Leave Oregon Job Protection (ORS § 657B.060):
- Employees who have worked for the employer for at least 90 days are entitled to job restoration after PLO leave
- As of January 1, 2026, BOLI enforces PLO job protection and anti-retaliation provisions

10. BENEFITS DURING LEAVE

Health Insurance Continuation:
- FMLA/OFLA: Employer must maintain group health insurance under the same terms (29 U.S.C. § 2614(c); ORS § 659A.174)
- Employee must continue to pay their share of premiums

Paid Leave Oregon Wage Replacement:

Additional Paid Leave Substitution:

☐ I elect to substitute accrued paid leave concurrently with FMLA/OFLA leave
☐ I understand the employer may require substitution of accrued paid leave
☐ I intend to use Oregon sick time concurrently (for qualifying reasons)

11. OREGON-SPECIFIC NOTICES

Oregon Bureau of Labor and Industries (BOLI):
- OFLA complaints: File with BOLI within 1 year of the alleged violation
- PLO job protection complaints: File with BOLI (as of Jan. 1, 2026)
- Contact: BOLI, 800 NE Oregon Street, Suite 1045, Portland, OR 97232 | Phone: (971) 245-3844

Oregon Employment Department (OED):
- PLO claims and benefits: https://paidleave.oregon.gov/
- 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 size | 50+ (within 75 mi) | 25+ (OR) | All employers |
| Employee eligibility | 12 mo / 1,250 hrs | 180 days / 25 hrs/wk | $1,000 in base year |
| Duration | 12 weeks | 12 weeks (+12 pregnancy) | 12 weeks (+2 pregnancy) |
| Paid | No | No | Yes |
| Job protection | Yes | Yes | Yes (90+ days) |

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
• OFLA provides up to 12 weeks of job-protected leave (plus 12 additional weeks for pregnancy disability)
• Paid Leave Oregon provides up to 12 weeks of paid benefits (plus 2 additional weeks for pregnancy)
• FMLA and OFLA generally run concurrently; PLO and OFLA do not run concurrently
• I must provide 30 days' advance notice when the need for leave is foreseeable
• I must provide medical certification if requested
• 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/OFLA/PLO-qualifying (check applicable)
☐ PROVISIONALLY APPROVED — Pending receipt of medical certification
☐ DENIED — Employee does not meet eligibility requirements
☐ MORE INFORMATION NEEDED — Specify: [________________________________]

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

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
• Oregon Family Leave Act, ORS §§ 659A.150–659A.186
• Paid Leave Oregon, ORS §§ 657B.010–657B.990
• Oregon Sick Time, ORS § 653.601 et seq.
• SB 69 (2025 — OFLA/PLO Alignment Amendments)
• 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: https://paidleave.oregon.gov/
• Oregon Employment Department: https://www.oregon.gov/employ/

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