FMLA Leave Request

FMLA leave request and certification routing form. Captures qualifying event, expected duration, and provider certification (DOL Form WH-380 reference).

Employee Information

• Employee Name
• Employee ID
• Department
• Work Email
• Manager Name

Leave Request Details

• Type of FMLA Leave
• Qualifying Event
• Requested Start Date
• Expected End Date
  If you do not know the end date, leave this blank and HR will follow up.
• Expected Frequency or Schedule
  For intermittent or reduced schedule leave, describe the expected pattern (for example, 2 mornings per week or occasional full days).
• Brief Reason for Leave
  Provide a brief description only. Do not include diagnosis details unless HR specifically requests certification.

Certification Routing

• Is medical certification expected?
• Healthcare Provider Name
  Enter the provider name only if you already have it and are comfortable sharing it for certification routing.
• Healthcare Provider Phone
• Healthcare Provider Fax
• Certification Form Reference
  Select the DOL certification form reference that best matches the leave reason.

Employee Attestation and Consent

• Consent to Use and Share Information for Leave Administration
• Employee Attestation
• Employee Signature
• Submission Date

HR Use Only

• HR Case Number
• Review Status
• HR Notes