Can an employee e-sign this form?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.

What if the medical certification is delayed?

Employers may provisionally designate leave and request certification. If certification is not provided within the time allowed, the employer may deny FMLA protection per internal policy and DOL guidance.

Is notarization required for FMLA requests?

No. FMLA documentation does not generally require notarization. State-specific programs may have different requirements for associated benefits, so verify local rules when applicable.

How should sensitive health data be handled?

Limit PHI on the form, transmit via secure channels, and use a Business Associate Agreement when a vendor handles protected health information under HIPAA.

Can an employee change a submitted request?

Yes. Amendments should be submitted in writing and logged. Employers should retain both original and amended records for audit and continuity purposes.

How long must these records be kept?

Retain leave documentation according to federal and state requirements; follow I-9, IRS, and HIPAA retention rules where applicable and consult counsel for complex situations.

Electronic Signature
Templates
HR
Employee FMLA Request Form

Employee FMLA Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE FMLA REQUEST FORM

Personal Information

Employee Name:

Employee ID Home Address

Work Phone

Personal Phone

Email

Position Information

Job Title

Department

Reporting Manager

Date Hired

Current Salary / Pay Rate

Requested Leave

Type of FMLA leave (check all that apply):

Own serious health condition
To care for a family member with serious health condition
Birth of a child or placement for adoption/foster care
Qualifying exigency related to covered active duty
Military caregiver leave

Anticipated Leave Start Date:

Anticipated Leave End Date:

Is this request for intermittent or reduced schedule leave? Yes No

If intermittent or reduced schedule, describe the expected pattern and duration Expected Return to Work Date

Medical Certification

I understand that a medical certification from my health care provider is required to support this request for FMLA leave and that failure to provide timely and sufficient certification may result in denial of leave or delay in designation. I hereby indicate:

I will provide medical certification
Medical certification already provided to HR

Health Care Provider Name

Provider Phone

Provider Address

Employee Statement of Medical/Family Need

Employment History (Most Recent)

Provide the two most recent employers. This information may be used to verify employment dates and leave eligibility.

Employer 1 — Company Name

Responsibilities Reason for Leaving Employer 2 — Company Name

Responsibilities Reason for Leaving

Education

Highest Degree Institution Graduation Date

References

Provide three professional references.

Reference 1 Reference 2 Reference 3

Legal Disclosures and Notices

At-Will Employment: Nothing in this form modifies the at-will employment relationship between the employee and the employer. The employer or employee may terminate employment at any time, with or without cause or advance notice, unless otherwise provided in a separate written agreement signed by an authorized representative of the employer.

Equal Opportunity: The employer provides equal employment opportunities in accordance with applicable law. Requests for reasonable accommodation related to leave will be considered in accordance with applicable law and company policy.

Employee Certification and Authorizations

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action up to and including termination.

I authorize the employer to contact my health care provider for clarification or verification of the medical certification and to contact prior employers for purposes related to leave eligibility verification. I further authorize the release of medical information necessary to determine FMLA eligibility, subject to applicable privacy protections.

I understand that I may be required to substitute accrued paid leave for unpaid FMLA leave in accordance with employer policy and that I must comply with the company's leave notification and certification procedures. I understand my rights and obligations under federal and applicable state family and medical leave laws.

Authorization to Contact Previous Employers and Background Checks

By signing below I consent to the employer contacting previous employers for the purpose of verifying employment dates and job duties as they relate to leave entitlement. I also understand that the employer may perform background checks where permitted by law in accordance with its policies.

I authorize previous employer contact and background checks as described above.

Applicant Certification

I certify that all information provided in this request is accurate and complete. I understand that I must provide requested documentation in a timely manner and that failure to comply may affect the approval of my leave.

Employee Printed Name:

Signature:

Date:

HR Use Only

Received By (HR Representative) Date Received Designation/Determination

What the Employee FMLA Request Form Is

The Employee FMLA Request Form is a written record an employee uses to request leave under the federal Family and Medical Leave Act. It documents the reason for leave, anticipated start and return dates, and whether leave is continuous or intermittent. Employers use the form to determine eligibility, request medical certification, and to create leave-tracking records that support compliance with FMLA entitlements and employer policies.

Why a Standardized FMLA Request Form Matters

A consistent form centralizes required information, reduces back-and-forth, and creates an auditable record for FMLA eligibility and certification. Using a clear template helps employers meet notice and documentation duties while giving employees a predictable process.

Who Completes and Reviews This Form

Employees initiate the request; HR and direct supervisors handle review and tracking. Use the form whenever an employee seeks leave covered by FMLA.

Employees requesting protected leave due to their own serious health condition or a covered family member's condition.
Human Resources and leave administrators responsible for eligibility checks and recordkeeping.
Supervisors and payroll for coverage planning, shift adjustments, and benefits coordination.

Third parties such as treating clinicians may provide supporting medical certification; payroll and benefits teams use the completed form for pay and leave administration.

Step-by-Step: Submitting an FMLA Request

Follow these sequential steps to submit a complete request and minimize processing delays.

01

Prepare the form: Complete all required fields before submission.
02

Attach certification: Include clinician form or medical note when available.
03

Submit to HR: Use employer-specified routing or secure eSubmission.
04

Respond to follow-up: Provide additional information within requested timeframe.

Essential Elements of a Professional FMLA Request Form

A well-structured form captures legal, administrative, and logistical details so employers can process requests consistently and employees know what documentation is required.

Employee Info

Full legal name, employee ID, department, job title, work location and contact details so records and payroll match accurately.

Leave Details

Clear selection of leave type, reason, estimated start and end dates, and whether leave is intermittent or continuous.

Certification Field

Space to indicate medical certification enclosed or pending and to note the clinician contact for verification when permitted.

Benefits Impact

Section explaining how paid leave, health benefits, and accruals are affected during FMLA leave.

Employer Response

Area for HR to record eligibility determination, required documentation, and certification of FMLA designation or denial.

Signature Blocks

Employee signature and date plus HR reviewer signature and date to create an auditable record of submission and action.

Required Information: Fields Employers Should Capture

Employee Name: Full legal name

Employer ID: Company-assigned ID

Leave Reason: Medical or family reason

Dates Requested: Start and end dates

Certification Status: Attached or pending

Signatures: Employee and HR signed

Configuring an Online FMLA Request Workflow

Common configuration settings streamline routing, authentication, and record retention for electronic submission and review.

Field	Configuration
Required Fields	Make name, dates, and leave type mandatory
Attachments	Allow PDF or image uploads for certifications
Routing	Send to HR then to manager for acknowledgement
Retention	Auto-archive to secure records repository

Typical Electronic Submission Flow

An electronic request moves through defined stages from employee initiation to HR determination and final storage; each step is recorded in the audit trail.

Employee Upload: Employee completes form and attaches files
Authentication: Verify identity via employer method
HR Review: HR assesses eligibility and requests certification
Final Record: Signed copy stored with audit trail

Technical Considerations for eSubmission

Ensure the platform supports secure uploads, audit trails, and appropriate signer authentication for employee health data.

File Types: PDF, DOCX, JPEG supported
Integrations: HRIS and payroll connectors
Security: TLS in transit; AES-256 at rest

Key Timing Rules and Expectations

Timelines for FMLA requests vary by circumstance; knowing common response windows reduces disputes and protects rights for both employee and employer.

Advance Notice:

30 days when leave is foreseeable

Employer Response:

Eligibility notice typically within 5 business days

Certification Deadline:

Provide medical certification within the time specified by employer

Intermittent Leave:

Employer may request scheduling to minimize disruption

Return-to-Work:

Provide release if employer requires fitness-for-duty

Processing Milestones for a Request

Track these stages to ensure timely handling and maintain compliance with documentation requirements.

01

Request Received

Record submission timestamp and acknowledgments

02

Eligibility Check

Confirm FMLA eligibility and employee tenure

03

Certification Request

Ask for medical certification if needed

04

Designation Notice

Issue written designation of FMLA leave

Common Mistakes That Cause Delays

Incomplete dates or vague return-to-work estimates that force follow-up and delay approval.
Omitting clinician contact or failing to attach medical certification when required by employer policy.
Using inconsistent names or IDs leading to misfiled records and payroll mismatches.
Submitting files in non-supported formats or with unreadable scans that require resubmission.

Risks and Consequences of Poor Documentation

FMLA Interference: Legal exposure

Discrimination Claims: Potential litigation

Payroll Errors: Back pay or benefits issues

Certification Gaps: Leave denial risk

Recordkeeping Violations: Administrative penalties

Reputational Harm: Employee relations impact

Comparing eSignature Options for FMLA Requests

Basic pricing and feature differences influence total cost and compliance capabilities; choose a provider that supports HIPAA, audit trails, and integrations with HR systems.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	Yes	Yes	Yes	Yes
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About the Employee FMLA Request Form

Answers to common questions about completing, submitting, and storing FMLA request forms and how electronic signatures affect legal validity.

Need help? Contact support

Can an employee e-sign this form?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.
What if the medical certification is delayed?
Employers may provisionally designate leave and request certification. If certification is not provided within the time allowed, the employer may deny FMLA protection per internal policy and DOL guidance.
Is notarization required for FMLA requests?
No. FMLA documentation does not generally require notarization. State-specific programs may have different requirements for associated benefits, so verify local rules when applicable.
How should sensitive health data be handled?
Limit PHI on the form, transmit via secure channels, and use a Business Associate Agreement when a vendor handles protected health information under HIPAA.
Can an employee change a submitted request?
Yes. Amendments should be submitted in writing and logged. Employers should retain both original and amended records for audit and continuity purposes.
How long must these records be kept?
Retain leave documentation according to federal and state requirements; follow I-9, IRS, and HIPAA retention rules where applicable and consult counsel for complex situations.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now