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. §§ 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. West Virginia Parental Leave Act

Under W.Va. Code §§ 21-5D-1 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 for the employer
- Employees with less than 12 consecutive months of employment are also entitled to 12 weeks of unpaid leave following exhaustion of annual, available sick, and personal leave

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)

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 only

9. Job Restoration Rights

Under Federal FMLA:
- Restoration to the same or an equivalent position with same pay, benefits, and conditions
- Key employee exception may apply for certain highly compensated salaried employees

Under West Virginia Parental Leave Act (W.Va. Code § 21-5D-4):
- Employee is entitled to be restored to the position of employment held when the leave commenced, or to an equivalent position with equivalent employment benefits, pay, and other terms and conditions of employment
- The taking of leave shall not result in the loss of any employment benefit accrued prior to the 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

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. West Virginia-Specific Notes

Coordination of Federal FMLA and WV Parental Leave Act:
- When both laws apply (state/county employees meeting federal FMLA thresholds), leave generally runs concurrently
- 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

Private-Sector Employees:
- Private-sector employees in West Virginia have no state-level family or medical leave protections
- Federal FMLA is the sole statutory basis for job-protected leave
- No state-mandated paid family leave, paid sick leave, or disability insurance program exists

Notice Requirements:
- Federal FMLA requires 30 days' advance notice for foreseeable leave
- State employees should follow their agency's leave request procedures and timelines

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

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 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 compliance with W.Va. Code §§ 21-5D-1 through 21-5D-7 (WV Parental Leave Act) and 29 U.S.C. §§ 2601-2654 (federal FMLA).