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Run: FMLA Leave Request Form

An FMLA Leave Request Form that captures employee details, leave dates, qualifying reason, and healthcare provider certification in one place. Use it to rout...

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Employee Information

Employee Name (required)

Employee ID (required)

Work Email (required)

Department

Leave Request Details

Type of Leave (required)

Qualifying Reason for Leave (required)

Requested Start Date (required)

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? (required)

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. (required)

Yes No N/A

I consent to HR contacting me or my healthcare provider for clarification related to this request. (required)

Yes No N/A

Employee Signature (required)

Date Signed (required)

Get your results

Enter your email — we'll send you a PDF of your filled-out template. We won't sign you up to anything; you can opt in to the trial from the email if you want.

Email (required)

Your name (optional)

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