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Run: FMLA Leave Request Form

Use this FMLA Leave Request Form to collect the employee details, leave dates, qualifying reason, and certification information HR needs to start a leave rev...

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Employee Information

Employee Name (required)

Employee ID

Optional if your organization uses an employee ID for routing.

Department (required)

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 (required)

Requested Start Date (required)

Requested End Date

Required for continuous leave if the expected end date is known.

Reason for Leave (required)

Provide a brief summary of the qualifying reason. Do not include more medical detail than necessary.

Qualifying Reason Category (required)

Intermittent or Reduced Schedule Details

Expected Frequency of Leave (required)

Example: 2 times per week, or 4 hours per day.

Expected Duration of Each Absence (required)

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 (required)

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. (required)

Yes No N/A

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.

Yes No N/A

Employee Signature (required)

Signature Date (required)

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Email (required)

Your name (optional)

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