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.

The composition of families in the United States has changed significantly in the past few decades. A major legal requirement regarding family-oriented benefits is the Family and Medical Leave Act (FMLA), which provides for unpaid leaves of absence.

The Family and Medical Leave Act of 1993 (FMLA) is a United States labor law requiring covered employers to provide employees with job-protected and unpaid leave for qualified medical and family reasons. The FMLA was enacted in 1993 and has been amended several times. It covers all federal, state, and private employers with 50 or more employees who live within 75 miles of the workplace.

Only employees who have worked at least 12 months and 1,250 hours in the previous year are eligible for leave under the FMLA. The law provides for unpaid leave; however, some companies pay short-term disability benefits during FMLA leaves under certain conditions.

A serious health condition is an illness or injury that requires inpatient care or continuing treatment by a health care provider for medical problems that exist beyond three days. An employer may require a medical certificate from a health care provider to support the reason for the employee’s leave.

Since the enactment of the FMLA, a significant percentage of employees have taken family and medical leave.

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