FMLA Leave Request Form

FMLA Leave Request Form — Form Fields

This hr template includes 10 fields. Collect employee information for Family and Medical Leave Act (FMLA) leave requests with qualifying reason details. Free to customize and use on ZenBuild.

• Employee Full Name (text, required)
• Work Email (email, required)
• Employee ID (text, required)
• Department and Manager (text, required)
• Proposed Leave Start Date (text, required)
• Anticipated Return Date (text, required)
• FMLA Qualifying Reason (dropdown selection, required) — options: Serious health condition (employee), Care for spouse/child/parent with serious condition, Birth and bonding with new child, Adoption or foster placement, Qualifying military exigency, Care for covered servicemember
• Leave Type Requested (multiple choice, required) — options: Continuous leave, Intermittent leave, Reduced schedule leave
• Will you be using accrued PTO concurrently? (multiple choice, required) — options: Yes, No
• Additional information for HR (long text, optional)