FMLA Leave Request Form - Rhode Island

FMLA LEAVE REQUEST FORM — RHODE ISLAND

Table of Contents

1. Employee Information
2. Employer Information
3. Leave Type Requested
4. Federal FMLA Overview
5. Rhode Island Parental and Family Medical Leave Act
6. Rhode Island Temporary Caregiver Insurance (TCI)
7. Leave Schedule and Duration
8. Intermittent or Reduced Schedule Leave
9. Medical Certification
10. Job Restoration Rights
11. Benefits Continuation
12. Rhode Island-Specific Notes
13. Employee Certification and Signature
14. Employer Response

1. Employee Information

2. Employer Information

3. Leave Type Requested

Check all that apply:

Federal FMLA Qualifying Reasons (29 U.S.C. § 2612):
☐ Birth of a child and bonding
☐ Placement of a child for adoption or foster care
☐ Care for spouse, child, or parent with a serious health condition
☐ Employee's own serious health condition
☐ Qualifying exigency arising from military service of a family member
☐ Care for a covered servicemember with a serious injury or illness (Military Caregiver Leave)

Rhode Island PFMLA Qualifying Reasons (R.I. Gen. Laws § 28-48-1):
☐ Parental leave — birth of a child
☐ Parental leave — placement for adoption of a child (16 years of age or younger)
☐ Family leave — serious illness of employee
☐ Family leave — serious illness of a family member (spouse, child, parent, mother-in-law, father-in-law)

Rhode Island Paid Leave Programs:
☐ Temporary Disability Insurance (TDI) — employee's own medical condition
☐ Temporary Caregiver Insurance (TCI) — bonding or care of seriously ill family member

4. Federal FMLA Overview

The federal Family and Medical Leave Act (29 U.S.C. §§ 2601-2654) provides eligible employees with:

• Up to 12 workweeks of unpaid, job-protected leave in a 12-month period
• Up to 26 workweeks for military caregiver leave in a single 12-month period
• Eligibility: Employed at least 12 months; worked at least 1,250 hours in the 12 months preceding leave; worksite with 50+ employees within 75 miles

5. Rhode Island Parental and Family Medical Leave Act

Under R.I. Gen. Laws §§ 28-48-1 through 28-48-12:

• Leave Duration: Up to 13 consecutive workweeks in any two (2) calendar years
• Eligibility: Full-time employee averaging at least 30 hours per week who has been employed for 12 consecutive months
• Covered Employers: Private employers with 50+ employees; state government (all branches); municipal employers with 30+ employees
• Qualifying Events: Birth of a child; adoption placement (child age 16 or under); serious illness of a family member (spouse, child, parent, in-laws); employee's own serious illness
• Notice: 30 days advance notice required unless medical emergency

6. Rhode Island Temporary Caregiver Insurance (TCI)

Under R.I. Gen. Laws §§ 28-41-34 through 28-41-42:

• Benefit Duration: Up to 8 weeks per benefit year (effective January 1, 2026)
• Purpose: Bonding with a new child or caring for a seriously ill family member
• Funding: Employee payroll contributions to the Temporary Disability Insurance fund
• Benefit Amount: Based on wages; calculated similarly to TDI benefits
• Job Protection: Available for employees of covered employers

☐ I intend to apply for TCI benefits concurrent with my unpaid leave
☐ I intend to apply for TDI benefits concurrent with my unpaid leave
☐ I do not intend to apply for RI paid leave benefits at this time

7. Leave Schedule and Duration

Type of Leave Schedule:
☐ Continuous leave (one uninterrupted block)
☐ Intermittent leave (see Section 8)
☐ Reduced schedule leave (see Section 8)

Reason for Dates Selected:
[________________________________]
[________________________________]

8. Intermittent or Reduced Schedule Leave

Complete only if requesting intermittent or reduced schedule leave.

☐ I understand intermittent leave under RI PFMLA must be consecutive unless my employer agrees otherwise
☐ Employer has agreed to intermittent or reduced schedule leave arrangement

9. Medical Certification

Applicable when leave is for a serious health condition.

☐ Medical certification from a health care provider is attached
☐ If my employer requests certification for federal FMLA leave, I will submit it within 15 calendar days after the employer's request, unless the employer allows more time or timely submission is not practicable despite diligent, good-faith efforts
☐ Not applicable — leave is for birth/adoption bonding only

10. Job Restoration Rights

Under both federal FMLA and Rhode Island PFMLA:

• Employees returning from leave are entitled to restoration to the same or equivalent position
• Equivalent position means same pay, benefits, terms, and conditions of employment
• RI PFMLA (R.I. Gen. Laws § 28-48-3): Employee must be restored to same or comparable position with same status, pay, employment benefits, length-of-service credit, and seniority

☐ I request information about job restoration protections and any applicable limits
☐ I understand I must return on or before the agreed end date of my leave

11. Benefits Continuation

☐ I request information about group health coverage during leave
☐ I understand I must continue paying my share of health insurance premiums
☐ I understand failure to pay my premium share may result in loss of coverage
☐ I wish to discuss benefit continuation options with HR

12. Rhode Island-Specific Notes

Coordination of State and Federal Leave:

• When both federal FMLA and RI PFMLA apply, the leaves generally run concurrently
• RI PFMLA provides 13 consecutive workweeks in any two calendar years; federal FMLA provides 12 weeks in a 12-month period
• RI TCI benefits may be used during unpaid leave to provide wage replacement

Key Rhode Island Distinctions:

• RI PFMLA covers employers with as few as 30 employees (municipal) compared to federal FMLA's 50-employee threshold
• RI PFMLA includes in-laws (mother-in-law and father-in-law) as covered family members; federal FMLA does not
• RI PFMLA measures leave entitlement over a 2-calendar-year period rather than a rolling 12-month period
• RI requires 30 days' advance notice unless a medical emergency prevents it

Employer Posting Requirements:

• Employers must post notice of employee rights under RI PFMLA in a conspicuous location (R.I. Gen. Laws § 28-48-5)

13. Employee Certification and Signature

I certify that the information provided in this request is true and accurate to the best of my knowledge. I understand that fraudulently obtaining FMLA leave can remove FMLA restoration and group-health-maintenance protections under 29 C.F.R. § 825.216(d). I have read and understand the leave rights described in this form under both federal FMLA and Rhode Island law.

14. Employer Response

Federal FMLA: provide the eligibility notice within five business days after the request or knowledge that leave may qualify, absent extenuating circumstances. This is not an automatic five-day approval deadline; provide the separate rights-and-responsibilities and designation notices required by 29 C.F.R. § 825.300.

☐ Leave request APPROVED under federal FMLA
☐ Leave request APPROVED under Rhode Island PFMLA
☐ Leave request APPROVED under both federal FMLA and RI PFMLA (concurrent)
☐ Leave request DENIED — reason: [________________________________]
☐ Additional information or certification required: [________________________________]

This form is provided as a template by ezel.ai and does not constitute legal advice. Rhode Island employers should consult with qualified employment law counsel regarding compliance with R.I. Gen. Laws Chapter 28-48 (RI PFMLA), R.I. Gen. Laws Chapter 28-41 (TDI/TCI), and 29 U.S.C. §§ 2601-2654 (federal FMLA).