FMLA Leave Request Form - Pennsylvania

FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA & Pennsylvania Supplemental Leave Provisions

(29 U.S.C. §§ 2601 et seq. | 43 Pa. Stat. § 955)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. Pennsylvania 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. Pennsylvania-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 (a private employer with 50 or more employees for at least 20 workweeks in the current or prior calendar year, or a covered public agency or school regardless of size)
• 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. PENNSYLVANIA STATE LEAVE PROVISIONS

No State Family or Medical Leave Act:

• Pennsylvania 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
• Pennsylvania does not operate a state-funded paid family and medical leave program

Pennsylvania Human Relations Act (43 Pa. Stat. § 955):

• Employers with 4 or more employees may not discriminate based on sex, 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

PHRA Pregnancy and Childbirth Rules (16 Pa. Code §§ 41.101–41.104):

• Pregnancy- or childbirth-related disability must receive the same leave, job-security, reinstatement, seniority, benefit, and disability-plan treatment as other temporary or permanent disabilities
• An employer may not impose an automatic maternity-leave date or require an employee to remain away after recovery
• If an employer offers childrearing or child-care leave beyond disability, the policy must apply equally without regard to sex and include birth and adoption

Local Paid Sick Leave Ordinances:

Philadelphia Promoting Healthy Families and Workplaces Ordinance (Phila. Code § 9-4100):

• Employers with 10 or more employees: up to 40 hours of paid sick leave per year
• Employers with fewer than 10 employees: up to 40 hours of unpaid sick leave per year
• Accrual: 1 hour per 40 hours worked

Pittsburgh Paid Sick Days Act:

• Employers with 15 or more employees: up to 40 hours of paid sick leave per year
• Employers with fewer than 15 employees: up to 24 hours of paid sick leave per year

Allegheny County Paid Sick Leave (eff. Dec. 7, 2025):

• Employers with 26 or more employees: up to 40 hours of paid sick leave per year
• Smaller employers: up to 24 hours of unpaid sick leave

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)
☐ PHRA pregnancy- or childbirth-related disability treatment / leave

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

☐ If requested, medical certification submitted through the employer’s designated process (form, if any): [________________________________]
☐ If requested, certification will be provided by: [__/__/____]
☐ If requested, military-family certification submitted through the designated process (form, if any): [________________________________]
☐ The employer has not requested certification.

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)

Pennsylvania Protections:

• Pennsylvania does not have a state-level job restoration requirement beyond federal FMLA
• However, termination or demotion for exercising protected pregnancy-related disability treatment or leave rights may violate:
• The PA Human Relations Act (43 Pa. Stat. § 955)
• PHRA pregnancy and childbirth regulations (16 Pa. Code §§ 41.101–41.104)
• Federal Pregnancy Discrimination Act (42 U.S.C. § 2000e(k))

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 local paid sick leave (Philadelphia/Pittsburgh/Allegheny Co.) concurrently
☐ I understand the employer may require substitution of accrued paid leave

11. PENNSYLVANIA-SPECIFIC NOTICES

Pennsylvania Human Relations Commission (PHRC):

• Employees who believe they have been discriminated against for exercising leave rights or based on pregnancy may file a complaint with the PHRC within 180 days of the alleged discriminatory act
• Contact: PHRC, 333 Market Street, 8th Floor, Harrisburg, PA 17101 | Phone: (717) 787-4410

Federal Claims:

• FMLA complaints may be filed with the U.S. Department of Labor, Wage and Hour Division (Philadelphia or Pittsburgh District Offices)
• Pregnancy discrimination complaints may be filed with the EEOC within 300 days (cross-filed with PHRC)

Local Sick Leave Enforcement:

• Philadelphia: Complaints filed with the Philadelphia Commission on Human Relations or the Mayor's Office of Labor
• Pittsburgh: Complaints filed with the Pittsburgh Commission on Human Relations
• Allegheny County: Complaints filed with the Allegheny County Health Department

Pending Legislation:

• The PA Family Care Act (HB 200, 2025-2026 session) would create a state PFML program with 12-20 weeks of paid leave — currently tabled as of November 2025

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
• Pennsylvania does not have a state paid family and medical leave program
• 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
• Fraudulently obtaining FMLA leave can remove FMLA restoration and group-health-maintenance protections under 29 C.F.R. § 825.216(d)

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

13. EMPLOYER RESPONSE

☐ Request received on [__/__/____].
☐ Eligibility and rights/responsibilities notices provided separately on [__/__/____].
☐ Certification requested separately on [__/__/____], if applicable.
☐ Designation notice provided separately on [__/__/____], after review.

Period stated in separate designation notice, if issued: [__/__/____] through [__/__/____]

Reason stated in separate notice, 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
• Pennsylvania Human Relations Act, 43 Pa. Stat. § 955
• Pennsylvania PHRA pregnancy and childbirth regulations, 16 Pa. Code §§ 41.101–41.104
• Philadelphia Paid Sick Leave, Phila. Code § 9-4100
• Pittsburgh Paid Sick Days Act
• Allegheny County Paid Sick Leave (eff. Dec. 7, 2025)
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• PA Human Relations Commission: https://www.phrc.pa.gov/
• Philadelphia Commission on Human Relations: https://www.phila.gov/departments/philadelphia-commission-on-human-relations/

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