FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — SOUTH DAKOTA

Table of Contents

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

1. Employee Information

2. Employer Information

Employer Type:
☐ Private-sector employer
☐ State of South Dakota 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 Dakota State Employee PFML (if applicable):
☐ Paid Family Medical Leave — qualifying FMLA event (state employees only)

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

Qualifying Reasons:

• Birth of a child and bonding within 12 months of birth
• Placement of a child for adoption or foster care and bonding within 12 months of placement
• Care for a spouse, son or daughter, or parent with a serious health condition
• Employee's own serious health condition rendering the employee unable to perform essential job functions
• Qualifying exigency related to a family member's active duty or call to active duty
• Care for a covered servicemember with a serious injury or illness (26 weeks)

5. South Dakota State Employee Leave Benefits

Paid Family Medical Leave (PFML) for State Employees:

• South Dakota state employees may be eligible for paid family medical leave for qualifying FMLA events
• Eligible employees may receive up to 40 hours per week for up to 12 weeks per year
• Eligibility: Must have worked for the state at least 12 months and 1,250 hours or more
• PFML runs concurrently with federal FMLA

☐ I am a South Dakota state employee requesting PFML benefits
☐ I am a private-sector employee requesting federal FMLA leave only

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 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 Dakota-Specific Notes

No State FMLA Law for Private Sector:

• South Dakota has not enacted a state family and medical leave law applicable to private-sector employers
• Private-sector employees rely exclusively on federal FMLA for job-protected family and medical leave
• There is no state-mandated paid family leave or paid sick leave law for private employers
• No South Dakota municipality has enacted a local paid leave ordinance

State Employee Benefits:

• State government employees may access Paid Family Medical Leave (PFML) for qualifying FMLA events
• PFML eligibility mirrors federal FMLA requirements (12 months employment, 1,250 hours worked)
• State employees should contact the Bureau of Human Resources for specific PFML procedures

Employer Voluntary Benefits:

• Some South Dakota employers voluntarily offer paid family leave, short-term disability, or other leave benefits
• Employees should review their employer's leave policies and any applicable collective bargaining agreements

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 Dakota state provisions.

13. Employer Response

To be completed by employer within five (5) business days of receiving this request.

☐ Leave request APPROVED under federal FMLA
☐ Leave request APPROVED under SD state employee PFML
☐ Leave request APPROVED under both federal FMLA and SD PFML (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 Dakota 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.