Mass FMLA Leave Request Form

MASS FMLA LEAVE REQUEST FORM

Employer / Event Identification

Employer Name:

HR Contact Name:   HR Contact Phone:

Mass Event Identifier (if applicable):   Estimated Number of Employees Affected:

Personal Information

Position Information

Date of Hire:   Current Hourly/Salary Rate:

Leave Request Details

Type of FMLA Leave Requested (check all applicable):

Employee's own serious health condition    Care for family member with serious health condition

Birth of child / bonding after birth or placement    Qualifying exigency or military caregiver leave

Leave anticipated to begin:   Anticipated end date:

Is leave to be taken intermittently or on a reduced schedule? Yes No

Medical Certification / Health Care Provider

Health Care Provider Name:

Provider Address:

Provider Phone:

Attached now    Employee will provide within required time frame

Employee Employment History (Most Recent)

Dates Employed:

Previous Employment (Prior to Most Recent)

Dates Employed:

Education

Graduation Date:

References (Professional)

Phone:   Email:

Phone:   Email:

Phone:   Email:

Legal Disclosures & Employee Acknowledgments

Eligibility and Rights Notice: Employees who meet the employer's eligibility requirements are entitled to job-protected leave under the Family and Medical Leave provisions administered by this employer. Approved leave may be unpaid or paid, as required or permitted by employer policy and law. Job restoration is subject to applicable reinstatement rules and any required fitness-for-duty certification.

Medical Certification Requirement: The employer requires appropriate medical certification to support leave for a serious health condition. Failure to provide requested certification within the time frame permitted by employer policy may result in delay or denial of leave. Medical information will be treated as confidential and maintained separately from personnel files.

Substitution of Paid Leave: Employee elects that accrued paid leave be substituted for unpaid FMLA leave where permitted. Employer policy governs the order and use of paid leave while on FMLA.

At-Will Employment: Nothing in this form alters the at-will employment relationship between the employee and the employer, except as required by law or separate written agreement.

Equal Employment Opportunity: The employer does not discriminate on the basis of protected characteristics in employment, leave administration, or related personnel actions.

Authorizations and Certifications

Authorization to Contact Providers and Employers: By signing below, I authorize the employer and its designated representatives to contact the health care provider(s) identified on this form and to obtain relevant medical information necessary to determine FMLA eligibility and to contact prior employers as necessary to verify employment history related to FMLA eligibility.

Background Check Consent: I authorize the employer to conduct background and reference checks where permitted by law to verify information supplied in this form. I understand that information obtained will be used only for employment-related decisions consistent with law.

Employee Certification: I certify that all information provided on this form is true, correct, and complete to the best of my knowledge. I understand that falsification or omission of material facts may result in disciplinary action, including denial of leave or termination.

I authorize contact with my health care provider(s) for medical certification purposes.

I consent to background/reference checks as described above.

I certify that the information provided is true and complete and I understand the consequences of false statements.

Additional Information / Notes (HR use)

Sign Now