FMLA Leave Request Form - South Carolina

FMLA LEAVE REQUEST FORM — SOUTH CAROLINA

Table of Contents

1. Employee Information
2. Employer Information
3. Leave Type Requested
4. Federal FMLA Overview
5. South Carolina State Employee Leave Provisions
6. Leave Schedule and Duration
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. South Carolina-Specific Notes
12. Employee Certification and Signature
13. Employer Response

1. Employee Information

2. Employer Information

Employer Type:
☐ Private-sector employer
☐ State of South Carolina agency or department
☐ County or municipal government
☐ School district
☐ Other public entity: [________________________________]

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)

South Carolina State Employee Paid Parental Leave (S.C. Code Ann. §§ 8-11-150, 8-11-155):
☐ Six (6) weeks paid leave — birth of a child to the employee
☐ Two (2) weeks paid leave — co-parent's birth of a child or foster placement under § 8-11-150
☐ Six (6) weeks paid leave — adoption placement where the employee is primarily responsible for care and nurture (§ 8-11-155)
☐ Two (2) weeks paid leave — adoption placement where the employee is not primarily responsible for care and nurture (§ 8-11-155)

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. South Carolina State Employee Leave Provisions

Paid Parental Leave (S.C. Code Ann. §§ 8-11-150, 8-11-155):

• Available to eligible state employees occupying any percentage of a full-time-equivalent position
• Six (6) weeks of paid leave at 100% of base pay for an employee who gives birth
• Two (2) weeks of paid leave at 100% of base pay for other § 8-11-150 qualifying events, including a co-parent's birth or foster placement
• For adoption under § 8-11-155, six (6) weeks applies to the employee primarily responsible for care and nurture; another eligible state-employee parent receives two (2) weeks
• Leave must be used within 12 months of the qualifying event
• Runs concurrently with federal FMLA when applicable

State Employee Sick Leave (S.C. Code Ann. § 8-11-40):

• Permanent full-time state employees accrue 15 days of paid sick leave per year
• Sick leave may accumulate up to a maximum of 180 days
• Part-time employees receive prorated benefits

Voluntary Paid Family Leave Insurance Act (S.C. Code Title 38, Chapter 103):

• Enacted May 2024; authorizes insurance carriers to offer voluntary paid family leave policies
• Employer participation is not mandatory
• Provides a private-market option for employers wishing to offer paid family leave benefits

☐ I am a state employee requesting paid parental leave under § 8-11-150
☐ I am a private-sector employee requesting federal FMLA leave only
☐ My employer offers voluntary paid family leave insurance

6. Leave Schedule and Duration

Type of Leave Schedule:
☐ Continuous leave (one uninterrupted block)
☐ Intermittent leave (see Section 7)
☐ Reduced schedule leave (see Section 7)

Reason for Dates Selected:
[________________________________]
[________________________________]

7. Intermittent or Reduced Schedule Leave

Complete only if requesting intermittent or reduced schedule leave.

☐ I understand that intermittent leave for bonding requires employer consent
☐ My leave is medically necessary on an intermittent basis (certification attached)

8. Medical Certification

Applicable when leave is for a serious health condition.

☐ Medical certification from a health care provider is attached
☐ Medical certification will be submitted within 15 calendar days
☐ Not applicable — leave is for birth/adoption bonding only

9. Job Restoration Rights

Under federal FMLA:

• Employees returning from FMLA leave are entitled to restoration to the same or an equivalent position
• Equivalent position means same pay, benefits, terms, and conditions of employment
• Key employee exception: Certain highly compensated salaried employees (top 10% at the worksite) may be denied restoration if it would cause substantial and grievous economic injury to the employer

☐ I acknowledge my right to job restoration upon timely return from leave
☐ I understand I must return on or before the agreed end date of my leave

10. Benefits Continuation

☐ I elect to continue group health insurance 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

11. South Carolina-Specific Notes

No State FMLA Equivalent for Private Sector:

• South Carolina does not have a state family and medical leave act applicable to private-sector employers
• Private-sector employees rely exclusively on federal FMLA for job-protected leave
• There is no state-mandated paid family leave program for private-sector workers

State Employee Protections:

• State employees benefit from both federal FMLA and state-specific paid parental leave under S.C. Code Ann. § 8-11-150
• State employee paid parental leave runs concurrently with federal FMLA

Voluntary Insurance Option:

• The Paid Family Leave Insurance Act (S.C. Code Title 38, Chapter 103), enacted May 2024, allows licensed insurance carriers to offer voluntary paid family leave policies to employers
• Coverage is not mandatory; employers may choose to purchase policies

Pending Legislation (not current law as of July 30, 2026):

• H.3490 and H.3645 (2025-2026 session) proposed expanding paid parental leave. H.3645 passed the House and remains in the Senate Finance Committee; H.3490 remains in the House.

12. 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 providing false or misleading information may result in denial of leave, disciplinary action, or termination. I have read and understand the leave rights described in this form under federal FMLA and any applicable South Carolina state provisions.

13. 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 SC state employee paid parental leave (§ 8-11-150)
☐ Leave request APPROVED under both federal FMLA and SC paid parental leave (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. South Carolina employers should consult with qualified employment law counsel regarding compliance with 29 U.S.C. §§ 2601-2654 (federal FMLA) and applicable state employee leave provisions.