FMLA Leave Request

This template covers the core intake fields HR needs to open an FMLA case: employee information, leave type, qualifying event, expected dates, frequency, and certification routing. It also includes employee attestation and consent so the form can document what was submitted and what happens next. The HR Use Only section gives your team a place to track case status and notes.

Use this form whenever an employee is requesting leave that may fall under FMLA and you need a consistent record for review. It is especially useful when the leave may be intermittent, when certification is needed, or when HR must route the case to a provider form such as WH-380. Ad-hoc email works poorly here because it often misses required fields and creates inconsistent documentation.

It is typically completed once per leave request or once per qualifying event, then updated if the expected duration or frequency changes. For intermittent leave, the same request may support ongoing tracking while HR records updates separately. The form is not meant to replace ongoing absence tracking or return-to-work documentation.

The employee should complete the request fields, including the leave details and attestation. HR should review the submission, confirm whether certification is required, and update the HR Use Only section with case status and notes. A manager may be copied for operational planning, but the form should not require them to collect medical details.

Yes. The Certification Routing section captures whether certification is required and records provider contact details so HR can route the request appropriately. The WH-380 reference field helps connect the intake form to the certification process without over-collecting medical information in the request itself. Keep the routing fields limited to what HR actually needs.

A common mistake is making every field required, which can block employees from submitting a request before they have all details. Another is asking for too much medical information in the brief reason field instead of using progressive disclosure and certification routing. Teams also sometimes forget to include a clear consent statement and a note about what happens after submission.

You can add conditional logic for intermittent versus continuous leave, or show provider fields only when certification is required. Many teams also add policy acknowledgments, preferred contact method, or a return-to-work follow-up field. Keep customization aligned with data minimization so the form only collects PII and leave details that HR will actually use.

Yes. The form can feed an HR case number, route submissions to a case queue, and trigger notifications to HR when a request is submitted. It also works well with document storage for certification attachments and audit trails for review status changes. If you integrate it, preserve the original submission record so HR can see what the employee entered.

A structured form is easier to review, easier to audit, and less likely to miss required fields than email or chat. It also supports validation, conditional logic, and a clearer consent flow for PII. Email can still be used for follow-up, but the request itself is better captured in a form that creates a consistent record.