FMLA Leave Request Form - Virginia

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 qualifying family member, including a person who meets the care-dependence test in Va. Code § 60.2-800

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: Generally 80% of the covered individual's average weekly wages, capped at 100% of state average weekly net earnings
• Qualifying Reasons: Care for a new child after birth, adoption, or foster placement; care for a family member with a serious health condition; the worker's own qualifying serious health condition; covered military-related reasons; or safety services, subject to the statutory conditions
• 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: Restoration generally applies to a covered individual who receives benefits and has worked for the current employer for at least 120 days before the leave

Timeline:

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
☐ If my employer requests certification for federal FMLA leave, I will submit it within 15 calendar days after the employer's request, unless the employer allows more time or timely submission is not practicable despite diligent, good-faith efforts
☐ 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: A salaried eligible employee among the employer's highest-paid 10% within 75 miles of the worksite may be denied restoration if restoration would cause substantial and grievous economic injury and the employer follows the required notice and return procedures, including a fresh injury determination if the employee requests reinstatement at the end of leave.

Under Virginia PFML (benefits begin December 1, 2028):

• A covered individual who receives benefits and has worked for the current employer for at least 120 days before the leave generally has a right to return to the same or an equivalent position under Va. Code § 60.2-808(A)

☐ I request information about job restoration protections and any applicable limits
☐ I understand I must return on or before the agreed end date of my leave

10. Benefits Continuation

☐ I request information about group health 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 November 2026):

• Virginia currently relies primarily on federal FMLA for job-protected family and medical leave
• The Virginia paid family and medical leave insurance program has been enacted; benefits begin December 1, 2028
• Current Virginia paid sick leave law covers qualifying home health workers. The 2026 expansion to broader employee coverage takes effect July 1, 2027; its one-hour-per-30-hours rule and 40-hour annual limit should not be treated as a current statewide entitlement

Virginia PFML Act Key Features:

• Covered individuals who meet the program's earnings and application requirements may receive up to 12 weeks of benefits in a benefit year; Commonwealth employees have separate state leave policies
• Benefits generally equal 80% of the covered individual's average weekly wages, capped at 100% of state average weekly net earnings
• Family members include specified relatives and domestic partners, plus a person who meets the statute's household or care-relationship and dependence conditions
• 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

Before Virginia PFML benefits begin:

• Use this form to request federal FMLA leave and ask HR about any currently applicable paid sick leave, employer policy, or other leave rights

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 fraudulently obtaining FMLA leave can remove FMLA restoration and group-health-maintenance protections under 29 C.F.R. § 825.216(d). I have read and understand the leave rights described in this form under federal FMLA and any applicable Virginia 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.

☐ Federal FMLA leave designated
☐ Federal FMLA leave not designated — reason: [________________________________]
☐ Additional information or certification required: [________________________________]

Virginia paid family and medical leave benefits (beginning December 1, 2028): The Virginia Employment Commission receives and pays claims under Va. Code § 60.2-801. An employer may instead have a Commission-approved private plan under § 60.2-816. This employer response records leave administration; it does not decide a claim for state-program benefits.

☐ Employee directed to the Commission for a state-program benefits claim
☐ Employee directed to the administrator of a Commission-approved private plan
☐ State paid-benefit claim route does not yet apply

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).