FMLA Leave Request

Dear [Employer Name],

 

RE: Request for Family and Medical Leave (FMLA)

 

I am writing to formally request leave under the Family and Medical Leave Act (FMLA) for the following reason:

 

[Reason for leave, e.g. 'The birth of my child and bonding with the new baby', 'My own serious health condition', 'To care for my spouse/parent/child who has a serious health condition']

 

LEAVE DETAILS

- Start date: [Start Date]

- Expected end date: [End Date, or 'undetermined']

- Duration: [Duration, e.g. '12 weeks', 'intermittent — 3 days per month']

 

I understand that under FMLA, eligible employees are entitled to up to 12 weeks of unpaid, job-protected leave per year. I have been employed with the company for over 12 months and have worked at least 1,250 hours in the past 12 months, making me eligible for FMLA leave.

 

I will provide medical certification from my healthcare provider (Form WH-380-E for my own serious health condition, or WH-380-F for family member's condition) within 15 calendar days of this request, unless it is not practicable under the circumstances.

 

During my leave, I would like to arrange for coverage of my duties. Please let me know:

1. Whether my leave is approved;

2. Whether I need to use accrued paid time off concurrently with FMLA leave;

3. Arrangements for continuing health insurance coverage during my leave;

4. Any other requirements or forms I need to complete.

 

I will keep you informed of any changes to my expected return date and will provide updates as needed.

 

 

NOTE: This is a template for guidance. Use the official DOL forms (WH-380-E, WH-380-F) for medical certification. See dol.gov/agencies/whd/fmla for full eligibility requirements.