FMLA Leave Request Form - West Virginia

FMLA LEAVE REQUEST FORM — WEST VIRGINIA

Table of Contents

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

1. Employee Information

2. Employer Information

Employer Type:
☐ Private-sector employer
☐ State of West Virginia department, division, board, bureau, agency, or commission
☐ County board of education
☐ 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)

West Virginia Parental Leave Act (W.Va. Code § 21-5D-4):
☐ Birth of a son or daughter
☐ Placement of a son or daughter for adoption
☐ Care for son, daughter, spouse, parent, or dependent with a serious health condition

4. Federal FMLA Overview

The federal Family and Medical Leave Act (29 U.S.C. §§ 2611-2614) provides eligible employees with:

• Up to 12 workweeks of job-protected leave in a 12-month period; leave may be unpaid or include substituted paid leave where permitted
• Up to 26 workweeks for military caregiver leave in a single 12-month period
• Eligibility: Employed at least 12 months and worked at least 1,250 hours in the preceding 12 months; the 50-employees-within-75-miles worksite exclusion and the Act's employer-coverage rules must also be evaluated

5. West Virginia Parental Leave Act

Under W. Va. Code §§ 21-5D-2 and 21-5D-4 through 21-5D-7:

Leave Duration:

• Up to 12 weeks of unpaid family leave in any 12-month period
• Leave is unpaid and is available only after the employee has exhausted all annual and personal leave

Eligibility:

• Employee hired for permanent employment who has worked for at least 12 consecutive weeks performing services for remuneration in West Virginia for a covered public employer; the statutory exclusions in § 21-5D-2(c)(2) must also be checked

Covered Employers:

• State government: Any department, division, board, bureau, agency, commission, or other unit of state government
• County boards of education
• Not applicable to private-sector employers

Qualifying Reasons:

• Birth of a son or daughter of the employee
• Placement of a son or daughter with the employee for adoption
• Care for the employee's son, daughter, spouse, parent, or dependent who has a serious health condition

6. Leave Schedule and Duration

Accrued Leave Status (required for WV PLA):

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 may require employer consent
☐ My leave is medically necessary on an intermittent basis (certification attached)

West Virginia PLA scheduling: Leave to care for a covered person with a serious health condition may be intermittent when medically necessary. Part-time leave is permitted, but the period in which it is taken may not exceed twelve consecutive months and must be scheduled so as not to disrupt the employer's operations unduly.

8. Medical Certification

Complete only if the employer requests certification for a qualifying reason for which certification is permitted.

☐ Medical certification from a health care provider is attached
☐ Medical certification will be submitted within 15 calendar days after the employer's request, unless the regulation permits additional time
☐ Not applicable — no certification has been requested for this leave reason

9. Job Restoration Rights

Under Federal FMLA:

• Restoration to the same or an equivalent position with equivalent pay, benefits, and conditions, subject to the Act's exceptions
• Key employee exception may apply for certain highly compensated salaried employees

Under West Virginia Parental Leave Act (W. Va. Code § 21-5D-6):

• The position held immediately before leave must be held for a period not exceeding the twelve-week leave period, and the employee must be returned to that position
• The employer may use a temporary employee to fill the position during the leave
• The employer may not reduce or deny a benefit or seniority accrued before leave because the employee received family or medical leave

☐ 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

Federal FMLA: The employer maintains group-health coverage during qualifying leave at the level and under the conditions that would have applied during continuous employment. Complete the employer's premium-payment arrangement.

West Virginia PLA: The employer continues group-health coverage during state leave, but W. Va. Code § 21-5D-7(b) states that the employee pays the employer the premium costs of that coverage.

When the same absence qualifies under federal FMLA, apply the federal group-health-maintenance conditions as well; do not use the state-only premium line to reduce federal protection.

☐ Federal FMLA premium arrangement applies
☐ West Virginia PLA employee-paid premium-cost arrangement applies to state-only leave
☐ I wish to discuss the applicable benefit-continuation arrangement with HR

11. West Virginia-Specific Notes

Coordination of Federal FMLA and WV Parental Leave Act:

• When leave qualifies under both laws, it counts against both entitlements under 29 C.F.R. § 825.701; apply the more protective provision where the laws differ
• Both laws provide 12 weeks of leave in a 12-month period
• WV PLA has a shorter employment tenure requirement (12 consecutive weeks vs. 12 months under federal FMLA)

Key West Virginia Distinctions:

• WV PLA applies only to state government employees and county board of education employees — not private-sector employers
• WV PLA requires exhaustion of all annual and personal leave before unpaid leave begins
• WV PLA covers "dependents" in addition to sons, daughters, spouses, and parents
• WV PLA has a lower eligibility threshold: 12 consecutive weeks of employment (compared to 12 months / 1,250 hours under federal FMLA)
• WV PLA includes care for a dependent with a serious health condition as a qualifying reason
• Under § 21-5D-4(e), check whether another provision of the West Virginia Code already gives this employee the same family-leave rights

Notice Requirements:

• Federal FMLA generally requires at least 30 days' advance notice for foreseeable birth, placement, or planned medical treatment; if 30 days is not practicable, notice is due as soon as practicable. Foreseeable qualifying-exigency notice is due as soon as practicable.
• For foreseeable birth or adoption leave under the WV PLA, the employee must provide two weeks' written notice
• For foreseeable planned treatment or supervision under the WV PLA, the employee must make a reasonable scheduling effort and provide two weeks' written notice, subject to the health care provider's approval
• Follow the employer's usual notice procedures unless an applicable exception applies

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 both federal FMLA and, where applicable, the West Virginia Parental Leave Act.

13. Employer Response

Federal FMLA: provide the eligibility notice within five business days after a request or knowledge that leave may qualify, absent extenuating circumstances. The five-day rule is not an automatic deadline to approve or deny the leave request. Provide the separate rights-and-responsibilities and designation notices required by 29 C.F.R. § 825.300.

Complete the outcome below only after checking employer coverage, employee eligibility, qualifying reason, available leave, and any permitted certification. This intake record does not replace the separate FMLA notices.

☐ Determination pending — information or certification requested: [________________________________]
☐ Leave request APPROVED under federal FMLA
☐ Leave request APPROVED under WV Parental Leave Act (W.Va. Code § 21-5D-4)
☐ Leave request APPROVED under both federal FMLA and WV PLA (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. West Virginia employers should consult with qualified employment law counsel regarding the West Virginia Parental Leave Act and federal FMLA.