FMLA Leave Request Form

A structured form for employees to request FMLA leave, including qualifying reason, healthcare provider details, intermittent leave needs, and certification information.

Employee Information

• Employee Name
• Employee ID
  Optional if your organization uses an employee ID for routing.
• Department
• Work Location
  Optional location or site information if needed for leave coordination.
• Manager Name
  Optional if your HR team already has manager routing configured.

Leave Request Details

• Type of Leave Requested
• Requested Start Date
• Requested End Date
  Required for continuous leave if the expected end date is known.
• Reason for Leave
  Provide a brief summary of the qualifying reason. Do not include more medical detail than necessary.
• Qualifying Reason Category

Intermittent or Reduced Schedule Details

• Expected Frequency of Leave
  Example: 2 times per week, or 4 hours per day.
• Expected Duration of Each Absence
  Example: 2 hours, half day, or full day.
• Schedule Notes
  Add any scheduling details that may help HR coordinate coverage.

Healthcare Provider and Certification

• Healthcare Provider Name
  Optional until certification is submitted, if your process allows follow-up.
• Healthcare Provider Phone
  Optional contact information for certification follow-up.
• Healthcare Provider Fax
  Optional if your organization accepts faxed certification.
• Certification Status
• Certification Document
  Upload supporting certification if available.

Employee Attestation

• I certify that the information provided is true and complete to the best of my knowledge.
• I authorize HR to contact my healthcare provider only as needed to clarify certification information.
  Use only if your process requires provider follow-up and complies with applicable privacy rules.
• Employee Signature
• Signature Date