FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — VERMONT

Table of Contents

1. Employee Information
2. Employer Information
3. Leave Type Requested
4. Federal FMLA Overview
5. Vermont Parental and Family Leave Act (VPFLA)
6. Vermont Family and Medical Leave Insurance (VT-FMLI)
7. Leave Schedule and Duration
8. Intermittent or Reduced Schedule Leave
9. Medical Certification
10. Job Restoration Rights
11. Benefits Continuation
12. Vermont-Specific Notes
13. Employee Certification and Signature
14. 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)

VPFLA — Parental Leave (21 V.S.A. § 472; employers with 10+ employees):
☐ Birth of a child and bonding (within first year)
☐ Placement of adopted or foster child (up to age 18) and bonding (within first year)
☐ Recovery from childbirth or miscarriage

VPFLA — Family Leave (21 V.S.A. § 472; employers with 15+ employees):
☐ Care for a family member with a serious illness

VPFLA — Bereavement Leave (21 V.S.A. § 472; employers with 10+ employees):
☐ Bereavement leave following the death of a family member (up to 2 weeks / 10 workdays)

VPFLA — Safe Leave (21 V.S.A. § 472; employers with 10+ employees):
☐ Leave related to domestic violence, sexual assault, or stalking affecting employee or family member

VPFLA — Qualifying Exigency Leave (21 V.S.A. § 472; employers with 10+ employees):
☐ Military qualifying exigency leave

Short-Term Family Leave (21 V.S.A. § 472a):
☐ Short-term family leave (up to 4 hours in any 30-day period; up to 24 hours per year)

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. Vermont Parental and Family Leave Act (VPFLA)

Under 21 V.S.A. §§ 471-474, as amended by Act 32 of 2025 (effective July 1, 2025):

Overall Leave Entitlement:

• Up to 12 weeks of unpaid, job-protected leave in a 12-month period (all leave types combined)

Eligibility:

• Employee must have worked an average of at least 30 hours per week for the preceding 12 months

Covered Employers:

• Parental, bereavement, safe, and military exigency leave: Employers with 10 or more employees
• Family leave (serious illness of family member): Employers with 15 or more employees

Expanded Family Member Definition (Act 32):

• Child, parent, grandparent, grandchild, sibling, spouse, civil union partner, domestic partner

Parental Leave (21 V.S.A. § 472):

• Birth of a child and bonding within the first year
• Placement of adopted or foster child (up to age 18) and bonding within the first year
• Recovery from childbirth or miscarriage

Family Leave:

• Care for a family member with a serious illness

Bereavement Leave (new under Act 32):

• Up to 2 weeks (10 workdays) within the 12-week overall entitlement
• No more than 5 consecutive workdays per use
• Must be taken within one year of the family member's death

Short-Term Family Leave (21 V.S.A. § 472a):

• Up to 4 hours in any 30-day period, not to exceed 24 hours per year
• For routine medical, dental, or other appointments for family members
• Available from all employers (no minimum size)

6. Vermont Family and Medical Leave Insurance (VT-FMLI)

Vermont operates a voluntary paid family and medical leave insurance program:

• Not mandatory — employers may choose to participate
• Individual employees, self-employed workers, and employers with one employee may purchase individual coverage through the VT-FMLI individual purchasing pool (as of July 1, 2025)
• Provides wage replacement during qualifying leave events

☐ My employer participates in the VT-FMLI program
☐ I have purchased individual VT-FMLI coverage
☐ I do not have VT-FMLI coverage
☐ I am unsure whether I have VT-FMLI coverage

7. Leave Schedule and Duration

Type of Leave Schedule:
☐ Continuous leave (one uninterrupted block)
☐ Intermittent leave (see Section 8)
☐ Reduced schedule leave (see Section 8)

Reason for Dates Selected:
[________________________________]
[________________________________]

8. 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)

9. 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 bonding, bereavement, safe leave, or short-term family leave

10. Job Restoration Rights

Under Federal FMLA:

• Restoration to the same or an equivalent position with same pay, benefits, and conditions

Under VPFLA (21 V.S.A. § 472):

• Employees are entitled to return to the same or comparable position with the same seniority, pay, benefits, and other terms and conditions of employment
• Employer may not retaliate against an employee for requesting or taking leave

☐ 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

11. 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

12. Vermont-Specific Notes

Coordination of Federal FMLA and VPFLA:

• When both laws apply, leave generally runs concurrently
• Both laws provide 12 weeks of leave in a 12-month period
• VPFLA covers smaller employers (10+ for parental; 15+ for family leave) vs. federal FMLA (50+ employees)
• VPFLA eligibility requires 30 hours/week average over 12 months; federal FMLA requires 1,250 hours in 12 months

Key Vermont Distinctions:

• VPFLA includes broader family member definitions: grandparent, grandchild, sibling, domestic partner (federal FMLA covers only spouse, child, parent)
• Vermont adds bereavement, safe leave, and military exigency as qualifying VPFLA reasons (Act 32)
• Short-term family leave (§ 472a) provides additional leave for routine appointments (4 hours/30 days; 24 hours/year)
• Vermont's VT-FMLI voluntary insurance provides potential wage replacement during leave
• All VPFLA leave types share a single 12-week annual pool

Notice Requirements:

• Employees should provide reasonable advance notice of foreseeable leave
• For unforeseeable leave, notice should be given as soon as practicable

13. 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 Vermont Parental and Family Leave Act.

14. 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 VPFLA (21 V.S.A. §§ 471-474)
☐ Leave request APPROVED under both federal FMLA and VPFLA (concurrent)
☐ Short-term family leave request APPROVED under 21 V.S.A. § 472a
☐ 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. Vermont employers should consult with qualified employment law counsel regarding compliance with 21 V.S.A. §§ 471-474 (VPFLA), Act 32 of 2025, and 29 U.S.C. §§ 2601-2654 (federal FMLA).