FMLA REQUEST FORM
The Family and Medical Leave Act (FMLA) is a US federal law requiring covered employers to provide eligible employees with up to 12 weeks of unpaid, job-protected leave per year for qualified family and medical reasons. It ensures health benefits are maintained during the leave and requires employers to reinstate the employee to their original or equivalent job. An employee is eligible for FMLA leave if they have worked for a covered employer for at least 12 months (need not be consecutive), logged at least 1,250 hours in the 12 months preceding the leave, and work at a location with 50 or more employees within 75 miles.
If you are requesting this from your employer, you may have already received forms from their HR department. This should also be accompyanied by your job description, which is an important part of the FMLA form.
It is the employee's responsibility to return applicable FMLA forms back to their employer within 15 calendar days. If your forms are due within a week's time, we cannot guarantee the forms will be completed prior to their due date, so please send us information as quickly as you can so we can avoid delays.
Please fill out the form below to the best of your ability. We do not disclose any specific diagnosis on FMLA forms, other than pregnancy, without your consent. Please be as detailed as you can. We understand parts of the form may seem confusing, but we will contact you if there is anything requiring additional details.