FMLA Leave Request Form - Wyoming

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 Intake Record

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 a spouse's, son or daughter's, or parent's covered active duty or call to covered active duty
☐ 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 generally 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 (the months need not be consecutive, subject to the break-in-service rules in 29 C.F.R. § 825.110(b))
• Worked at least 1,250 hours in the 12 months immediately preceding the leave
• Employer employs 50 or more employees within 75 miles of the worksite; check special rules, including for airline flight crews

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 arising from a spouse's, son or daughter's, or parent's covered active duty or call to covered active duty
• Care for a covered servicemember with a serious injury or illness if the employee is the servicemember's spouse, son, daughter, parent, or next of kin (up to 26 weeks in a single 12-month period)

Notice Requirements:

• Foreseeable birth, placement, or planned medical-treatment leave: Generally at least 30 days' advance notice, or as soon as practicable if 30 days is not practicable; foreseeable qualifying exigency notice is due as soon as practicable
• Unforeseeable leave: Notice as soon as practicable under the circumstances and the employer's usual notice procedures, subject to applicable exceptions

Employer Obligations:

• Provide the federal eligibility notice within five business days after the request or knowledge that leave may qualify, absent extenuating circumstances, and separately provide the rights-and-responsibilities and designation notices required by 29 C.F.R. § 825.300
• Maintain group health insurance coverage during leave on the same terms as if the employee were actively working
• Restore an eligible employee to the same or an equivalent position upon return, subject to the limits in federal FMLA

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 (for example, optional DOL Form WH-380-E for the employee's own condition or WH-380-F for a family member's condition)
☐ If certification is requested, I will submit it within 15 calendar days after the employer's request, unless more time is allowed or timely submission is not practicable despite diligent, good-faith efforts
☐ Not applicable — leave is for birth, adoption, or foster-care bonding only

Certification Notes:

• Employer may request a second opinion at the employer's expense
• Employer may request recertification when the current FMLA regulations permit it; the timing depends on the certified duration, whether the minimum duration has expired, and 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:

• Eligible employees returning from FMLA leave generally are entitled to restoration to the same or an equivalent position, subject to applicable limits
• Equivalent position means same pay, benefits, terms, and conditions of employment
• Key employee exception: A salaried eligible employee among the employer's highest-paid 10% within 75 miles of the worksite may be denied restoration if restoration would cause substantial and grievous economic injury and the employer follows the required notice and return procedures, including a fresh injury determination if the employee requests reinstatement at the end of leave.
• To invoke the key-employee exception, the employer must give timely written notice of key status and potential consequences, notify the employee when it determines restoration would cause the required injury, allow an employee already on leave the opportunity to return, and redetermine injury if reinstatement is requested at the end of leave

☐ I have read the restoration information above and understand that the applicable limits must be reviewed
☐ I will notify the employer promptly if my expected return date changes

9. Benefits Continuation

☐ I want to retain my existing group health coverage during FMLA leave
☐ I choose not to retain group health coverage during FMLA leave; I request information about reinstatement of coverage on return
☐ If I retain coverage, I understand I must continue paying my share of health insurance premiums
☐ I understand that late premium payments may affect coverage under the applicable FMLA notice and grace-period rules
☐ I wish to discuss benefit continuation options with HR

Premium Payment Options:
☐ Voluntarily 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

Other leave and accommodation review:

☐ I request information about any applicable employer paid leave, disability, or other leave policy.

☐ I request review of any applicable state or local leave protection, accommodation right, contract, or collective bargaining agreement in addition to federal FMLA.

Employer policy or other program to review: [________________________________]

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 fraudulently obtaining FMLA leave can forfeit FMLA restoration and group-health-maintenance protections under 29 C.F.R. § 825.216(d). I have read and understand the leave information described in this form.

12. Employer Intake Record

Record receipt here. The employer must make its eligibility and designation decisions through the separate notices required by 29 C.F.R. § 825.300.

☐ Request received
☐ Eligibility notice sent separately
☐ Rights-and-responsibilities notice sent separately
☐ Designation notice sent separately when sufficient information was available
☐ Additional information or certification requested separately: [________________________________]

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).