FMLA Leave Request Form

FMLA LEAVE REQUEST FORM — WYOMING

Table of Contents

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

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 Requirements:

• Employed by a covered employer for at least 12 months (need not be consecutive)
• Worked at least 1,250 hours in the 12 months immediately preceding the leave
• Worksite has 50 or more employees within a 75-mile radius

Qualifying Reasons:

• Birth of a child and bonding within 12 months of birth
• Placement of a child for adoption or foster care and bonding within 12 months of placement
• Care for a spouse, son or daughter, or parent with a serious health condition
• Employee's own serious health condition rendering the employee unable to perform essential job functions
• Qualifying exigency related to a family member's active duty or call to active duty in the Armed Forces
• Care for a covered servicemember with a serious injury or illness (up to 26 weeks — Military Caregiver Leave)

Notice Requirements:

• Foreseeable leave: At least 30 days advance notice, or as soon as practicable
• Unforeseeable leave: Notice as soon as practicable (generally same day or next business day)

Employer Obligations:

• Provide written designation notice within five (5) business days of the request
• Maintain group health insurance coverage during leave on the same terms as if the employee were actively working
• Restore employee to the same or equivalent position upon return

5. Leave Schedule and Duration

Type of Leave Schedule:
☐ Continuous leave (one uninterrupted block)
☐ Intermittent leave (see Section 6)
☐ Reduced schedule leave (see Section 6)

Reason for Dates Selected:
[________________________________]
[________________________________]

6. 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)

7. Medical Certification

Applicable when leave is for a serious health condition.

☐ Medical certification from a health care provider is attached (DOL Form WH-380-E or WH-380-F)
☐ Medical certification will be submitted within 15 calendar days
☐ Not applicable — leave is for birth/adoption bonding only

Certification Notes:

• Employer may request a second opinion at the employer's expense
• Employer may request recertification every 30 days or upon changed circumstances
• If the first and second opinions differ, a third opinion (final and binding) may be obtained at the employer's expense

8. 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: Certain highly compensated salaried employees (top 10% at the worksite within 75 miles) may be denied restoration if it would cause substantial and grievous economic injury to the employer's operations
• Employer must notify the employee of key employee status when leave is requested or when leave begins

☐ 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

9. 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 (after 30-day grace period)
☐ I wish to discuss benefit continuation options with HR

Premium Payment Options:
☐ Pre-pay premiums before leave begins
☐ Pay premiums on regular payroll schedule during leave
☐ Pay premiums monthly during leave
☐ Other arrangement: [________________________________]

10. Wyoming-Specific Notes

No State Family or Medical Leave Law:

• Wyoming has not enacted any state family or medical leave law
• No state-mandated paid family leave program exists
• No state-mandated paid sick leave law exists
• No state disability insurance program exists
• No Wyoming municipality has enacted a local paid leave ordinance

Federal FMLA Is the Sole Protection:

• The federal FMLA provides the entire legal framework for job-protected family and medical leave in Wyoming
• Employees must meet all three federal FMLA eligibility requirements (12 months employed, 1,250 hours worked, 50+ employees within 75 miles)
• Employees who do not meet these thresholds have no statutory right to job-protected leave

Employer Voluntary Policies:

• Some Wyoming employers voluntarily offer paid family leave, short-term disability, or other leave benefits beyond federal FMLA requirements
• Employees should review their employer's leave policies, employee handbook, and any applicable collective bargaining agreements
• Employer-offered benefits do not change federal FMLA rights or obligations

Practical Considerations:

• Given Wyoming's significant rural and small-employer workforce, many employees may not meet the 50-employee-within-75-miles threshold for federal FMLA eligibility
• Employees of smaller employers should inquire about voluntary employer leave policies

11. 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 federal FMLA.

12. Employer Response

To be completed by employer within five (5) business days of receiving this request.

☐ Leave request APPROVED under federal FMLA
☐ Leave request DENIED — reason: [________________________________]
☐ Employee is not eligible for FMLA — reason: [________________________________]
☐ Additional information or certification required: [________________________________]

This form is provided as a template by ezel.ai and does not constitute legal advice. Wyoming employers should consult with qualified employment law counsel regarding compliance with 29 U.S.C. §§ 2601-2654 (federal FMLA).