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Run: FMLA Leave Request

FMLA Leave Request template for collecting the employee details, leave dates, qualifying event, and certification routing needed to start HR review. Use it t...

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Employee Information

Employee Name (required)

Employee ID (required)

Department (required)

Work Email (required)

Manager Name

Leave Request Details

Type of FMLA Leave (required)

Qualifying Event (required)

Requested Start Date (required)

Expected End Date

If you do not know the end date, leave this blank and HR will follow up.

Expected Frequency or Schedule

For intermittent or reduced schedule leave, describe the expected pattern (for example, 2 mornings per week or occasional full days).

Brief Reason for Leave

Provide a brief description only. Do not include diagnosis details unless HR specifically requests certification.

Certification Routing

Is medical certification expected? (required)

Healthcare Provider Name

Enter the provider name only if you already have it and are comfortable sharing it for certification routing.

Healthcare Provider Phone

Healthcare Provider Fax

Certification Form Reference

Select the DOL certification form reference that best matches the leave reason.

Employee Attestation and Consent

Consent to Use and Share Information for Leave Administration (required)

Yes No N/A

Employee Attestation (required)

Yes No N/A

Employee Signature (required)

Submission Date (required)

HR Use Only

HR Case Number

Review Status

HR Notes

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Email (required)

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