FMLA Leave Request Form
Employee Information
Full Name
Employee ID
Department
Position
Contact Number
Email Address
Leave Request Details
Type of Leave
Own Serious Health Condition
Family Member's Serious Health Condition
Birth/Adoption/Foster Care
Military Family Leave
Relationship (if applicable)
Leave Start Date
Leave End Date
Expected Duration of Leave (weeks/days)
Will leave be taken intermittently?
Yes
No
Explanation/Reason for Leave
Certification & Agreement
Employee Signature
Date