Paid Family Medical Leave Form

PAID FAMILY MEDICAL LEAVE REQUEST FORM

Use this form to request paid family or medical leave under the employer's Paid Family Medical Leave policy. Complete all applicable sections and attach required medical or supporting documentation. Submission of this form does not constitute approval of leave; approval will be determined according to policy eligibility, documentation, and operational needs.

Personal Information

Position and Employment

Employment start date:

Leave Request Details

Type of leave requested (select all that apply):

Bonding with a newborn, newly placed child, or adoption placement
To care for a family member with a serious health condition
For the employee's own serious health condition
Military caregiver leave
Qualifying exigency related to a family member's military service
Other (describe):

Leave anticipated to be: Continuous Intermittent or reduced schedule

Requested leave start date:

Anticipated return date:

Medical or Supporting Provider Information

I will provide medical certification or supporting documentation within the time required by policy. I understand the employer may require clarification or additional information from my provider and that my medical information will be maintained confidentially in separate medical records.

Employment History

Employer 1

Employment dates: to

Employer 2

Employment dates: to

Education

Graduation or completion date:

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures and Notices

At-Will Employment: Nothing in this form or in any statement made during the leave request process modifies the at-will nature of employment unless expressly stated in a separate written agreement signed by an authorized representative of the employer.

Equal Opportunity: The employer provides equal employment opportunities and will not unlawfully discriminate against employees or applicants on any protected characteristic in the administration of leave policies.

Confidentiality: Medical and health information provided in support of this request will be kept confidential and maintained in separate medical files, except as necessary to process the request or as required by law.

False Statements: Knowingly providing false or misleading information in connection with this request may result in disciplinary action, up to and including termination, and may require repayment of improperly paid benefits.

Authorization and Applicant Certification

I certify that all information provided on this form and any attached documentation is true and complete to the best of my knowledge. I authorize the employer and its designated agents to request and receive information from my health care provider(s) and prior employers as necessary to process this leave request and to verify eligibility. I understand that the employer may request additional documentation and that failure to provide requested documentation may result in denial of leave or removal of paid leave benefits.

I consent to the release of medical information limited to the minimum necessary to evaluate this request. I understand that this authorization is limited to the purpose of processing and administering the leave request and expires upon final determination of eligibility and benefits for this request.

Employer Use Only (Do not complete by applicant)

Approval status: Approved Denied Pending

Applicant Authorization to Contact Prior Employers and References

By signing below I authorize the employer to contact the prior employers and references listed on this form for the purpose of verifying employment dates, job duties, and other information pertinent to processing this leave request.

Applicant Certification (initials required)

Initial to certify: I confirm that the information provided is true and that I understand the employer's policies regarding paid family medical leave.

Sign Now