Free Family and Medical Leave Form
This Request for Family or Medical Leave is from an employee to an employer in order to request time off as a family or medical leave. This request sets out the name of the employee, the start and end dates of the leave and the specific reason why leave is being requested. This Request for Family or Medical Leave must be signed by the employee and accepted or declined by the employer.
Disclaimer:This was not drafted by an attorney & should not be used as a legal document.
Request for Family or Medical Leave
Employee Name: ____________________________
Employee Number: __________________________
I am requesting a Family and Medical Leave for the period starting from ________________________ and ending on ________________________.
This leave is requested for the following reasons:
____Birth of a child
____Caring for a newborn child
____Caring for a child placed for adoption or foster care
____Caring for a family member with a serious medical condition
____ My own serious medical condition
____ Military Family Leave because of a qualifying exigency (12 week maximum)
____ Military Family Leave to care for a covered service member with a serious injury or illness
Anticipated leave balances (in hours) at beginning of leave:
Annual leave: _____; Disability leave: _____: Compensatory time: _____
I hereby request leave/approved absence from duty as indicated above and certify that such leave/absence is requested for the purpose(s) indicated. I understand that I must comply with my employer’s procedures for requesting leave/approved absence and provide additional documentation, including medical certification, if required and that falsification on this form may be grounds for disciplinary action, including removal.
At the end of a Family and Medical Leave, I understand that I have to return to the job I held prior to the leave or an equivalent job. If the total leave exceeds ___________________ weeks and becomes a leave without pay for personal reasons, return rights shall be in accordance with policies for leave without pay for personal reasons.
Employee’ signature: __________________________
Official Action on request _______________ Accepted ___________________ Declined
Reason for Disapproval _______________________________________________________________________________________________________________________________________