FMLA Leave Request Form

A structured form for employees to request FMLA leave, document the qualifying reason, indicate whether leave is continuous or intermittent, and capture healthcare provider certification details.

Employee Information

• Employee Name
• Employee ID
• Work Email
• Department

Leave Request Details

• Type of Leave
• Qualifying Reason for Leave
• Requested Start Date
• Requested End Date
• Expected Frequency of Leave
  Describe the expected frequency and duration of intermittent or reduced schedule leave.
• Requested Hours per Day
  Enter the reduced daily hours if requesting a reduced schedule.
• Additional Context
  Provide any other details needed for HR to evaluate the request. Do not include unnecessary medical details.

Healthcare Provider Certification

• Will you submit healthcare provider certification?
• Healthcare Provider Name
• Healthcare Provider Phone
• Certification Date
• Upload Certification Document
  Upload the completed certification form or supporting documentation if available.

Employee Attestation

• I certify that the information provided is true and complete to the best of my knowledge.
• I consent to HR contacting me or my healthcare provider for clarification related to this request.
• Employee Signature
• Date Signed