FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — UTAH

Table of Contents

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

1. Employee Information

2. Employer Information

Employer Type:
☐ Private-sector employer
☐ State of Utah agency or department
☐ Local Education Agency (LEA) / school district
☐ County or municipal government
☐ 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)

Utah State Employee Leave (if applicable):
☐ Paid parental leave (up to 3 workweeks — state employees)
☐ Paid postpartum recovery leave (up to 3 workweeks — state employees)
☐ Paid safe leave — domestic violence / sexual assault / stalking (up to 1 workweek — state employees)

Utah Pregnancy Accommodation (Utah Code Ann. § 34A-5-106):
☐ Request for reasonable accommodation related to pregnancy, childbirth, breastfeeding, or related conditions

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. Utah State-Specific Provisions

Pregnancy Accommodation (Utah Code Ann. § 34A-5-106):

• Employers with 15 or more employees must provide reasonable accommodations for pregnancy, childbirth, breastfeeding, and related conditions upon request
• Accommodations may include modified duties, leave, or schedule adjustments
• Accommodation is not required if it would impose an undue hardship on the employer

State Employee Paid Parental Leave (Utah Code Ann. § 63A-17-510):

• Up to 3 workweeks of paid parental leave for bonding with a new child (birth, adoption, or foster placement)
• Up to 3 workweeks of paid postpartum recovery leave
• Runs concurrently with federal FMLA

State Employee Paid Safe Leave (effective January 1, 2025):

• Up to 1 workweek of paid safe leave per calendar year
• Available for employees who are victims of domestic violence, sexual assault, stalking, or human trafficking, or who have an immediate family member who is a victim

Local Education Agency (LEA) Leave (effective July 1, 2025):

• LEAs must develop leave policies providing parental and postpartum recovery leave on terms no more restrictive than those for state employees
• Extends the 3-workweek paid parental leave and 3-workweek postpartum recovery leave framework to K-12 public education workforce

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. Utah-Specific Notes

No State FMLA Law for Private Sector:

• Utah 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 family and medical leave
• No state-mandated paid family leave or paid sick leave law exists for private employers

Pregnancy Accommodation Requirements:

• Under Utah Code Ann. § 34A-5-106, employers with 15+ employees must provide reasonable accommodations for pregnancy, childbirth, breastfeeding, and related conditions
• This may include modified duties, temporary transfer, schedule adjustments, or leave as an accommodation
• Accommodations are required unless they impose an undue hardship

State and Public-Sector Employee Benefits:

• State employees receive up to 3 weeks paid parental leave plus up to 3 weeks paid postpartum recovery leave
• LEA employees (effective July 1, 2025) receive comparable parental and postpartum leave
• State employees also have access to paid safe leave (effective January 1, 2025)

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 Utah 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 Utah state employee paid parental leave
☐ Leave request APPROVED under both federal FMLA and state leave (concurrent)
☐ Pregnancy accommodation granted under Utah Code Ann. § 34A-5-106
☐ 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. Utah employers should consult with qualified employment law counsel regarding compliance with 29 U.S.C. §§ 2601-2654 (federal FMLA) and Utah Code Ann. § 34A-5-106 (pregnancy accommodation).