FMLA Leave Request Form - Vermont

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 son or daughter for adoption or foster care (subject to the federal definition)
☐ Care for spouse, child, or parent with a serious health condition
☐ Employee's own serious health condition
☐ Qualifying exigency arising from covered active duty of a spouse, son, daughter, or parent
☐ 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 (under age 18) and bonding (within first year)
☐ Recovery from childbirth or miscarriage

VPFLA — Family Leave (21 V.S.A. § 472; employers with 15+ employees):
☐ Employee's own serious health condition
☐ Care for a family member with a serious health condition

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)

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 generally must have worked for the same employer for one year averaging at least 30 hours per week; § 471(5), as amended by 2026 Act 177, also recognizes specified airline-flight-crew and full-time-teacher service rules

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 (under age 18) and bonding within the first year
• Recovery from childbirth or miscarriage

Family Leave:

• Employee's own serious health condition
• Care for a family member with a serious health condition

Bereavement Leave (new under Act 32):

• Up to 2 weeks 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 to eligible employees of employers covered by the VPFLA family-leave definition in § 471(4) (15 or more qualifying employees)

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
• A participating plan may provide wage replacement for covered leave; check the plan terms for eligibility, benefits, and claims

☐ My employer participates in the VT-FMLI program
☐ I have separately purchased voluntary leave coverage (details: [________________])
☐ 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

Complete this section if the employer requests certification for a serious health condition or military caregiver leave.

☐ 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
☐ Medical certification is not attached; I will respond to any applicable request for documentation

10. Job Restoration Rights

Under Federal FMLA:

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

Under VPFLA (21 V.S.A. § 472):

• Employees generally must be offered the same or a comparable position with the same seniority, pay, benefits, and other terms and conditions of employment, subject to the exceptions in § 472(f)
• Employer may not retaliate against an employee for requesting or taking leave

☐ I request information about job restoration protections and any applicable limits
☐ I will notify my employer if my expected return date changes

11. Benefits Continuation

☐ I request information about group health coverage during leave
☐ I request instructions for paying any employee share of health insurance premiums during leave
☐ I request information about how late premium payments may affect coverage
☐ I wish to discuss benefit continuation options with HR

12. Vermont-Specific Notes

Coordination of Federal FMLA and VPFLA:

• When an absence qualifies under both laws, it generally counts against both applicable leave entitlements
• Both laws generally provide up to 12 weeks of leave in a 12-month period for ordinary qualifying reasons; federal military caregiver leave has a separate 26-week entitlement
• VPFLA employer thresholds are 10 qualifying employees for parental leave and 15 for family leave; federal FMLA coverage and employee eligibility use different tests, including a general 50-employees-within-75-miles worksite test
• VPFLA generally requires one year with the employer averaging 30 hours/week, with the § 471(5) airline-flight-crew and full-time-teacher alternatives; federal FMLA generally requires 1,250 hours in the preceding 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:

• For Vermont leave under § 472, give reasonable written notice stating the expected start and duration; the employer may not require more than six weeks' advance notice for birth or adoption
• For short-term family leave under § 472a, give the earliest possible notice, generally at least seven days before leave except in an emergency
• For foreseeable federal FMLA leave, generally give 30 days' notice when practicable; for unforeseeable leave, give notice as soon as practicable under the circumstances

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 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 both federal FMLA and the Vermont Parental and Family Leave Act.

14. 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.

☐ 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).