FMLA Request Form Template – Employee Family & Medical Leave Application for HR | PDF and Word

Simplify employee leave requests with this professional FMLA Request Form Template, designed for HR departments, employers, managers, small businesses, and employees requesting qualifying family or medical leave.
This customizable Family and Medical Leave Act (FMLA) Employee Leave Application provides an organized way to document an employee’s requested leave, including the reason for leave, anticipated dates, continuous or intermittent leave schedule, supervisor information, eligibility review, and certification requirements.

Ideal for businesses looking to create a more consistent HR documentation process for employee family and medical leave requests.

WHAT’S INCLUDED
This FMLA Request Form includes sections for:
• Employee Information
• Employee ID
• Job Title & Department
• Supervisor / Manager Information
• Contact Information
• Date of Request
• Reason for Leave
• Employee Medical Leave
• Family Member Care Leave
• Birth of a Child
• Adoption or Foster Care Placement
• Military Family Leave
• Requested Start & End Dates
• Continuous / Full-Time Leave
• Intermittent Leave
• Reduced Work Schedule
• Eligibility Verification
• Certification Requirements
• Supporting Documentation
• Employee Acknowledgment
• Employee Signature & Date
• Employer / HR Review

The current product is provided in both PDF and editable Word formats for convenient customization and printing.

PERFECT FOR
• Human Resources Departments
• HR Managers
• Small Business Owners
• Employers
• Office Managers
• Employee Leave Administration
• Employee Records Management
• Family & Medical Leave Requests
• Employee Medical Leave
• Parental Leave Requests
• Military Family Leave
• Workplace HR Documentation
DOCUMENT FAMILY & MEDICAL LEAVE REQUESTS
Provide employees with a standardized way to formally submit a request for leave that may qualify under the Family and Medical Leave Act.
Use this template to help:

✓ Collect employee and supervisor information
✓ Document the reason for requested leave
✓ Record anticipated leave dates
✓ Identify continuous or intermittent leave
✓ Document reduced-schedule requests
✓ Organize eligibility information
✓ Track certification requirements
✓ Maintain consistent HR records
✓ Create a professional leave-request process

MULTIPLE FMLA LEAVE REASONS
The form accommodates several common reasons for requesting FMLA leave, including:
• Employee’s Own Serious Health Condition
• Care for a Qualifying Family Member
• Birth of a Child & Bonding
• Adoption or Foster Care Placement
• Qualifying Military Family Leave

These categories align with the leave-request options included in the current template.

CONTINUOUS, INTERMITTENT & REDUCED-SCHEDULE LEAVE
Not every employee needs the same type of leave.
The form allows employees to indicate whether they are requesting full-time/continuous leave, intermittent leave, or a reduced work schedule, helping HR document the requested leave arrangement from the beginning.

GREAT FOR HR & SMALL BUSINESSES
This form can be incorporated into an organization's broader employee leave-management process and used alongside:
• Employee Handbooks
• Leave of Absence Policies
• Attendance Policies
• Medical Certification Documents
• Return-to-Work Forms
• Employee Personnel Records
• HR Compliance Documentation

It provides employers with a reusable starting point rather than creating a new leave-request document every time an employee requests family or medical leave.

EDITABLE & PRINTABLE
Customize the template with your:
• Company name
• Business logo
• Contact information
• HR department information
• Employee information
• Supervisor information
• Leave dates
• Internal procedures
• Additional company-specific instructions

DIGITAL DOWNLOAD
This is a digital product. No physical item will be shipped.
Your purchase includes:

• PDF File
• Editable Word Document
• Instant Digital Download

The current Etsy listing confirms both PDF and Word formats are included.

After purchase, download the files, customize the applicable sections for your organization, and incorporate the form into your employee leave-request process.

IMPORTANT FMLA DISCLAIMER
This template is provided for general informational, administrative, and HR documentation purposes only and does not constitute legal, employment, medical, regulatory, or compliance advice.
This form does not determine whether an employee or employer is covered by or eligible for FMLA protections, and completing the form does not automatically approve or designate leave as FMLA-protected.

Employers may have additional notice, eligibility, certification, designation, recordkeeping, and employee-rights obligations under federal law. State and local family and medical leave laws may also provide additional or different requirements.

Employers should review current federal, state, and local requirements and use any required official notices or forms when applicable.

Due to the nature of digital products, all sales are final.