FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — TENNESSEE

Table of Contents

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

Tennessee Parental Leave Act (Tenn. Code Ann. § 4-21-408):
☐ Leave for pregnancy
☐ Leave for childbirth
☐ Leave for adoption
☐ Leave for nursing an infant

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. Tennessee Parental Leave Act

Under Tenn. Code Ann. § 4-21-408:

• Leave Duration: Up to four (4) months (approximately 16 weeks) of unpaid leave
• Qualifying Events: Pregnancy, childbirth, adoption, and nursing an infant
• Adoption: The 4-month period begins at the time the employee receives custody of the child
• Eligibility: Full-time employees who have been employed by the same employer for at least 12 consecutive months
• Employer Coverage: Employers with 100 or more full-time employees at the job site or location
• Applies to Both Parents: Male and female employees are equally eligible
• Notice Requirement: Employee must give at least three (3) months' advance notice of the anticipated date of departure, length of leave, and intention to return to full-time employment
• Medical Emergency Exception: If a medical emergency necessitates that leave begin before three months' notice has been given, the employee is still entitled to leave

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)

If requesting Tennessee Parental Leave:
| Field | Entry |
|-------|-------|
| Date Three-Month Advance Notice Given | [__/__/____] |
| Expected Date of Birth / Adoption Placement | [__/__/____] |
| Intended Return Date | [__/__/____] |

7. Intermittent or Reduced Schedule Leave

Complete only if requesting intermittent or reduced schedule leave.

☐ I understand that intermittent leave for bonding may require 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 or nursing only

9. Job Restoration Rights

Under Federal FMLA:

• Restoration to the same or an equivalent position with same pay, benefits, and conditions
• Key employee exception may apply for certain highly compensated salaried employees

Under Tennessee Parental Leave Act (Tenn. Code Ann. § 4-21-408):

• Employees who provide the required three (3) months' advance notice shall be restored to their previous or a similar position with the same status, pay, length-of-service credit, and seniority
• The employee is not entitled to accrual of seniority or employment benefits during the leave period
• The employer is not required to pay the employee during the leave

☐ I acknowledge my right to job restoration upon timely return from leave
☐ I have provided (or will provide) at least three months' advance notice as required under Tennessee law
☐ I understand that failure to provide required notice may affect my restoration rights

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. Tennessee-Specific Notes

Coordination of Federal FMLA and Tennessee Parental Leave Act:

• When both laws apply, leave generally runs concurrently
• Tennessee law provides up to 4 months of leave for pregnancy/childbirth/adoption/nursing — potentially longer than the 12-week federal FMLA entitlement
• After federal FMLA leave is exhausted, the employee may have additional leave remaining under Tennessee law
• Tennessee law covers employers with 100+ full-time employees at a job site; federal FMLA covers employers with 50+ employees within 75 miles

Key Tennessee Distinctions:

• Tennessee Parental Leave Act covers only pregnancy, childbirth, adoption, and nursing — it does not cover care for a sick family member or the employee's own serious health condition (those are covered only by federal FMLA)
• Tennessee requires three (3) months' advance notice (compared to 30 days under federal FMLA)
• Both male and female employees may take Tennessee parental leave
• Tennessee law does not require the employer to pay the employee during leave

State Employee Leave (Effective January 2026):

• State government employees have access to six (6) weeks of paid parental leave
• State government employees may also access six (6) weeks of paid caregiving leave for end-of-life family care situations (effective January 2026)

No State Paid Family Leave Program:

• Tennessee does not have a state-mandated paid family leave program for private-sector employees

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 both federal FMLA and the Tennessee Parental Leave Act.

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 Tennessee Parental Leave Act (§ 4-21-408)
☐ Leave request APPROVED under both federal FMLA and TN Parental Leave Act (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. Tennessee employers should consult with qualified employment law counsel regarding compliance with Tenn. Code Ann. § 4-21-408 (Tennessee Parental Leave Act) and 29 U.S.C. §§ 2601-2654 (federal FMLA).