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Free Employer Form • FMLA Leave

FMLA Employee Request Form

A compliant leave request form covering all six FMLA qualifying reasons and three leave types — the document that starts the employer’s notice clock correctly.

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FMLA administration is a game of deadlines that starts before most employers notice it has started. Once an employee gives enough information to suggest a qualifying reason — whether or not they say ’FMLA’ — the employer’s eligibility-notice obligations begin. A standard request form turns that fuzzy trigger into a clean, dated record.

This form captures the request completely: employee information, anticipated leave dates, the qualifying reason selected from all six categories — birth and bonding, adoption or foster placement, a family member’s serious health condition, the employee’s own condition, qualifying exigency, and military caregiver leave — and the leave type: continuous, reduced schedule, or intermittent. Guidance on 30-day advance notice and eligibility criteria is built in.

Who should use this form

  • HR administrators at employers with 50+ employees
  • Office managers processing their first FMLA request
  • Supervisors who need a standard way to route leave requests to HR
  • Employers formalizing leave intake before a TPA transition

What it helps prevent

  • Verbal leave requests that never become documented, datable records
  • Missed employer notice deadlines because no one logged the request date
  • Qualifying reasons captured incompletely, complicating designation
  • Intermittent leave handled without the right expectations set
  • Disputes about what was requested and when

What’s inside

  • Employee information and contact block
  • Requested leave dates — anticipated start and end
  • All six FMLA qualifying reason categories
  • Leave type selection — continuous, reduced schedule, intermittent
  • 30-day advance notice guidance for foreseeable leave
  • Eligibility criteria information for employees

Before you process payroll, terminate, classify, deduct, or respond to a claim, get the decision reviewed.

Faulkner HR Solutions helps Texas employers, nonprofits, municipalities, and growing businesses fix the people systems behind recurring workplace problems. If this resource raised a risk flag, do not guess your way through the next step.

Call 210.446.8730 Email thomas@faulknerhrsolutions.info

Frequently asked questions

Who is eligible for FMLA leave?
Employees of covered employers (generally 50 or more employees) who have worked for the employer at least 12 months, logged at least 1,250 hours in the preceding 12 months, and work at a site with 50 employees within 75 miles. The form’s information section reflects those criteria.
What happens after the employee submits this form?
The employer’s clock starts: an eligibility notice with rights and responsibilities generally within five business days, certification if required, and a designation notice once enough information exists. The FMLA Notice Timeline Tracker linked below manages those deadlines.
Can we require 30 days’ notice?
For foreseeable leave, yes — the form requests it. For unforeseeable leave, employees must give notice as soon as practicable, and you cannot deny protection for lack of 30 days’ notice when the need was not foreseeable.
Does the employee have to say ’FMLA’ to be protected?
No — providing enough information to suggest a qualifying reason is sufficient to trigger the employer’s obligations. The form standardizes intake, but train supervisors to route any leave-like conversation to HR rather than waiting for the magic word.

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Disclaimer. This resource is provided for general employer education and planning purposes. It is not legal advice and does not create an attorney-client relationship. Employment laws, agency guidance, and local requirements may change. Employers should review the facts of each situation before acting and consult appropriate HR or legal counsel when needed.