FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — VIRGINIA

Table of Contents

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

1. Employee Information

2. Employer Information

Employer Type:
☐ Private-sector employer
☐ Commonwealth of Virginia agency or department
☐ County or municipal government
☐ School division
☐ 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)

Virginia Paid Family and Medical Leave (effective December 1, 2028):
☐ Birth or adoption of a child
☐ Care for a seriously ill family member
☐ Employee's own serious medical condition
☐ Care for a family member or equivalent close associate

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. Virginia Paid Family and Medical Leave Act

Note: Benefits under this program are not available until December 1, 2028.

Key Provisions (as enacted in 2026):

• Leave Duration: Up to 12 weeks of paid leave
• Benefit Amount: 80% of average weekly wage, capped at 100% of the state average weekly wage
• Qualifying Reasons: Birth or adoption of a child; care for a sick family member; employee's own serious medical condition; care for any individual whose close association with the employee is equivalent to a family relationship
• Contributions: Employers and employees will both contribute to a state-administered fund beginning April 1, 2028
• Small Employer Exception: Employers with 10 or fewer workers are not required to pay the employer share of contributions
• Job Protection: Provided in conjunction with paid leave benefits

Timeline:
| Milestone | Date |
|-----------|------|
| Legislation enacted | 2026 |
| Contributions begin | April 1, 2028 |
| Benefits available | December 1, 2028 |

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

Under Virginia PFML (effective December 1, 2028):

• Job protection will be provided in conjunction with paid leave benefits
• Specific restoration provisions will be established through program regulations

☐ 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. Virginia-Specific Notes

Current Legal Landscape (as of April 2026):

• Virginia currently relies primarily on federal FMLA for job-protected family and medical leave
• The Virginia PFML Act has been enacted but benefits are not yet available (December 1, 2028)
• Virginia has enacted paid sick leave legislation (one hour per 30 hours worked, up to 40 hours annual accrual) — pending Governor signature

Virginia PFML Act Key Features:

• Nearly all workers in the Commonwealth will be eligible for up to 12 weeks of paid leave
• Benefits at 80% of average weekly wage, capped at 100% of state average weekly wage
• Broad definition of eligible family member, including "any individual whose close association with a covered individual is the equivalent of a family relationship"
• Both employer and employee contributions fund the program
• Small employers (10 or fewer workers) exempt from employer contribution share

State Employee Benefits:

• Commonwealth of Virginia employees may have access to additional leave benefits under the Virginia Sickness and Disability Program (Va. Code Ann. § 51.1-1100 et seq.)
• State employees should consult their agency HR for specific leave entitlements

No Current State FMLA Equivalent:

• Until the PFML program takes effect on December 1, 2028, there is no state-mandated family or medical leave law for private-sector employees beyond federal FMLA

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 Virginia 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 Virginia PFML (after December 1, 2028)
☐ Leave request APPROVED under both federal FMLA and VA 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. Virginia employers should consult with qualified employment law counsel regarding compliance with 29 U.S.C. §§ 2601-2654 (federal FMLA) and the Virginia Paid Family and Medical Leave Act (2026).