Free FMLA request form templates: general intake, own health condition, family care, military, and intermittent leave, plus an employer deadline checklist.
Six leave request templates for US small business: a general intake form, versions for the employee's own health condition, family care and bonding, military family leave, and intermittent or reduced-schedule leave, plus an employer processing checklist. Each carries a company-use block tracking the five-business-day and fifteen-calendar-day deadlines. Download as DOCX, no signup.
An FMLA request form is the intake document an employee fills in to tell you they need leave. It is the first step in a process with unforgiving deadlines, and it is also the one document in that process the government does not supply. There are official forms for the notices you send and for the certifications a doctor completes, but nothing for the request itself, which is why every employer ends up building or borrowing one.
There are six templates here: a general intake form covering every qualifying reason, dedicated versions for the employee's own health condition, family care and bonding, and military family leave, an intermittent and reduced-schedule version, and an employer processing checklist. Each downloads as an editable Word document, free and without an email. Each also carries a company-use block that puts the deadline dates on the form itself, because the five-business-day clock starts when the request arrives, not when you get to it. For the policy that sits behind all of this, see the FMLA policy template.
TL;DR
An FMLA request form is an internal intake document capturing who is asking, the qualifying reason, the leave pattern, and the dates, plus a company-use block for the eligibility determination. Download six free templates as DOCX: general, own health condition, family care and bonding, military, intermittent, and an employer checklist. Three things surprise small employers: the employee does not have to use your form or name the law, the deadlines are five business days for the eligibility notice, 15 calendar days for certification, and five business days for designation, and many businesses under 50 employees are not covered federally at all. This is general information, not legal advice.
What an FMLA Request Form Is
An FMLA request form is an internal intake document an employee completes to tell their employer they need leave under the Family and Medical Leave Act. It captures the employee and position, the qualifying reason by category, whether leave will be continuous or intermittent, the dates, and a paid-leave election, followed by a company-use section recording eligibility and the notice dates.
Three things it is not, all of which cause confusion. It is not an official government form, because none exists for the request itself. It is not the medical certification, which a health care provider completes later. And it is not an approval, since eligibility still has to be determined and written notices issued. It works alongside the return to work form at the other end of the leave.
The Form Is a Tool, Not a Gate
An employee does not have to use your form, and the first time they request leave for a qualifying reason they do not have to mention the law by name. They only have to give enough information for you to know the leave may be covered. A message to a supervisor about a hospital stay counts. Treating a request as not made because the form was not submitted is a common and expensive mistake, and the deadline clock starts when the company learns of the need, not when HR does. This is general information, not legal advice.
Are You Even Covered?
Most template pages skip this, and for a business in the 5 to 50 employee range it is the first thing worth checking. Coverage has two layers: whether you are a covered employer, and whether the individual employee is eligible. Both have to be satisfied.
Test
Requirement
Applies to
Employer coverage
50 or more employees in 20 or more workweeks in the current or preceding calendar year
The business
Length of service
Employed by you for at least 12 months
The employee
Hours of service
At least 1,250 hours in the 12 months before leave begins
The employee
Worksite size
50 or more employees within 75 miles of the work location
The employee
All three employee conditions must be met, not just one. A business with 30 people at a single location is generally not a covered employer federally. That is not the whole picture, though: several states run their own leave programs with lower employer thresholds and different eligibility rules, and those can apply where the federal law does not. Check the state rule for each state where you have employees before you decline anything.
What the Form Should Include
A complete request form covers four groups: who is asking, why, when and how, and the company-use block. The groups below are the consensus set that strong intake forms share.
Who is asking
Name, ID, job title, department
Supervisor and contact during leave
Date of hire, for the eligibility check
Why
Qualifying reason by checkbox
Family relationship, where relevant
No diagnosis field, deliberately
When and how
Continuous, intermittent, or reduced schedule
Start date and expected return date
Whether 30 days notice was possible
Company use only
Eligibility determination and date received
Notice, certification, and designation dates
Outcome and any fitness-for-duty requirement
Two design choices matter more than they look. Ask for the category of reason rather than a diagnosis, since medical detail belongs on the certification and has to be filed separately anyway. And build the deadline dates into the company-use block, because a form that records when the eligibility notice is due is the cheapest compliance control available.
Which Template Should You Use?
The general form handles every case and is the right default for a small team. The reason-specific versions collect better information and read more clearly to the employee, which matters if you handle leave requests often enough to justify keeping four forms rather than one.
General Request Form
The default
One intake form covering every qualifying reason and every leave pattern, with a paid-leave election, an employee acknowledgment, and a company-use block that tracks the eligibility notice, certification, and designation deadlines in one place.
Own Health Condition
Most common case
Tuned for leave for the employee's own serious health condition. Adds planned-treatment scheduling, coordination with disability or state paid leave, and a note that any fitness-for-duty requirement has to be flagged in the designation notice.
Family Care and Bonding
Birth, adoption, caregiving
For bonding with a new child or caring for a spouse, child, or parent. Captures the relationship, notes the 12-month window on bonding leave, and flags that intermittent bonding leave generally needs employer agreement.
Military Family Leave
Exigency and caregiver
For a qualifying exigency arising from covered active duty, or military caregiver leave. Includes the exigency categories and the separate entitlement that applies to caregiver leave rather than the standard one.
Intermittent / Reduced Schedule
Not one block of time
For leave taken in separate absences or as reduced hours. Captures the expected pattern, sets the call-in procedure for unplanned absences, and covers tracking increments and temporary transfer.
Processing Checklist
The deadline clock
The employer-side workflow: the coverage and eligibility test first, then the five-business-day eligibility notice, the 15-calendar-day certification window, the five-business-day designation notice, and the return.
One Form Is Usually Enough for a Small Team
If you process a handful of leave requests a year, use the general form and skip the variations. Four forms means four things to keep updated and one more chance to hand someone the wrong one. The case for the reason-specific versions is different: they ask better questions, particularly for intermittent leave and military family leave where the general form has to stay generic. Pick based on volume, not on completeness. This is general information, not legal advice.
6 Free FMLA Request Form Templates
Download all six together or take individual documents. The general form covers everything; the four reason and pattern variations ask sharper questions; the processing checklist is the employer-side workflow with the deadline clock built in.
Download All 6 FMLA Request Templates
A general leave request form, versions for the employee's own health condition, family care and bonding, and military family leave, an intermittent and reduced-schedule request, and an employer processing checklist. All as DOCX files in one download.
Template 1: General FMLA Leave Request Form
One intake form covering every qualifying reason and leave pattern, with a paid-leave election, an employee acknowledgment, and a company-use block tracking eligibility, the notices, and the certification window in one place.
FMLA Leave Request Form
FMLA LEAVE REQUEST FORM
[Company Name]
Submit this completed form to [name or role] at [email or location]. Submitting
this form starts the process; it is not an approval. You will receive a written
notice of your eligibility and rights within five business days.
Note: you are not required to use this form or to say the words family and
medical leave in order to request leave. This form exists so we capture the same
information every time and can respond within the deadlines the law sets.
SECTION 1: EMPLOYEE INFORMATION
Name: __ Employee ID: __
Job title: __ Department: __
Supervisor: __
Work phone: __ Personal phone: __
Email for leave correspondence: __
Date of hire: _
SECTION 2: REASON FOR LEAVE
Check the reason that applies:
•[ ] My own serious health condition that makes me unable to perform my job
•[ ] The birth of my child, and to care for the newborn
•[ ] The placement of a child with me for adoption or foster care
•[ ] To care for my [ ] spouse [ ] child [ ] parent with a serious health
condition
•[ ] A qualifying exigency arising from a family member's covered active duty
or call to covered active duty
•[ ] To care for a covered servicemember with a serious injury or illness
(military caregiver leave)
If caring for a family member, relationship: __
You do not need to describe a diagnosis on this form. A certification form may be
requested separately.
SECTION 3: TYPE AND TIMING OF LEAVE
•[ ] Continuous leave: a single block of time away from work
•[ ] Intermittent leave: separate blocks of time for a single condition
•[ ] Reduced schedule: fewer hours per day or per week
Requested start date: _
Expected return date: _ [ ] Unknown at this time
If intermittent or reduced schedule, describe the expected pattern as best you
can, for example two appointments per month or four hours per day:
__
Was this leave foreseeable at least 30 days in advance? [ ] Yes [ ] No
If no, briefly explain why earlier notice was not possible:
__
SECTION 4: PAID LEAVE SUBSTITUTION
Leave under the Family and Medical Leave Act is unpaid. Accrued paid leave may
run at the same time as this leave.
•[ ] I elect to use my accrued paid leave during this leave
•[ ] I prefer to take this leave unpaid, subject to company policy
•[ ] I would like to discuss my options before deciding
Types of accrued leave to apply, if elected: [ ] PTO [ ] Vacation [ ] Sick
[ ] Other: __
SECTION 5: EMPLOYEE ACKNOWLEDGMENT
I understand that:
•Submitting this form starts a process and is not itself an approval
•I may be asked to provide a certification from a health care provider, and I
will generally have at least 15 calendar days to return it
•I should keep [name or role] informed if my dates or circumstances change
•My group health coverage continues during approved leave on the same terms
Employee signature: __ Date: _
SECTION 6: FOR COMPANY USE ONLY
Date request received: _ Received by: __
Eligibility review:
•Employed at least 12 months? [ ] Yes [ ] No
•At least 1,250 hours of service in the 12 months before leave? [ ] Yes [ ] No
•Works at a site with 50 or more employees within 75 miles? [ ] Yes [ ] No
Eligibility and Rights and Responsibilities Notice (Form WH-381) sent on:
_ (Due within five business days of the request.)
Certification requested: [ ] Yes, form: _ [ ] No
Certification due back by: _ (Allow at least 15 calendar days.)
Certification received on: _
Designation Notice (Form WH-382) sent on: _
(Due within five business days of having enough information to decide.)
Fitness-for-duty certification will be required on return: [ ] Yes [ ] No
DISCLAIMER: This is a sample template for general information only and is not
legal advice. The federal law applies to private employers with 50 or more
employees in 20 or more workweeks; smaller employers may not be covered federally
but may have obligations under state leave laws. Have a qualified employment
attorney review before use.
Template 2: Own Serious Health Condition
Tuned for the most common case. Adds planned-treatment scheduling, coordination with disability or state paid leave, and a note that any fitness-for-duty requirement must be flagged in the designation notice rather than sprung at the end.
Request Form: Employee's Own Serious Health Condition
FMLA LEAVE REQUEST: OWN SERIOUS HEALTH CONDITION
[Company Name]
Use this version when the leave is for your own serious health condition. Submit
to [name or role] at [email or location].
SECTION 1: EMPLOYEE
Name: __ Employee ID: __
Job title: __ Department: __
Supervisor: __ Date of hire: _
Contact during leave: __
SECTION 2: NATURE OF THE REQUEST
I am requesting leave because of my own health condition, which makes me unable
to perform one or more of the essential functions of my position.
Do not describe your diagnosis here. If a certification is requested, your health
care provider will supply the medical information.
Have you already been treated or scheduled for treatment? [ ] Yes [ ] No
Is any part of this leave for planned medical treatment? [ ] Yes [ ] No
If yes, have you discussed scheduling with your supervisor to reduce disruption?
[ ] Yes [ ] Not yet
SECTION 3: LEAVE PATTERN
•[ ] Continuous leave from _______________ to _______________
For bonding with a new child or caring for a spouse, child, or parent with a serious health condition. Captures the relationship, notes the 12-month window on bonding leave, and flags that intermittent bonding leave generally needs employer agreement.
Request Form: Family Care and Bonding Leave
FMLA LEAVE REQUEST: FAMILY CARE OR BONDING
[Company Name]
Use this version for leave to care for a family member with a serious health
condition, or to bond with a new child. Submit to [name or role] at [email or
location].
SECTION 1: EMPLOYEE
Name: __ Employee ID: __
Job title: __ Department: __
Supervisor: __ Date of hire: _
SECTION 2: REASON
•[ ] Birth of my child and bonding with the newborn
•[ ] Placement of a child with me for adoption or foster care
•[ ] To care for my spouse with a serious health condition
•[ ] To care for my child with a serious health condition
•[ ] To care for my parent with a serious health condition
For bonding leave, date of birth or placement: _
Note on bonding leave: entitlement to bonding leave generally ends 12 months
after the birth or placement.
For family care leave, relationship to the person you are caring for:
__
If the person is your child and is 18 or older, note that additional conditions
apply to caring for an adult child. [Company Name] may ask for information
confirming the family relationship.
SECTION 3: LEAVE PATTERN
•[ ] Continuous leave from _______________ to _______________
Note: intermittent or reduced-schedule bonding leave generally requires the
employer's agreement, unlike leave for a serious health condition.
Requested start date: _ Expected return: _
Was this leave foreseeable at least 30 days in advance? [ ] Yes [ ] No
SECTION 4: PAID LEAVE AND BENEFITS
•[ ] I elect to use accrued paid leave during this leave
•[ ] I will take the leave unpaid, subject to company policy
•[ ] I am also applying for state paid family leave: _______________________
SECTION 5: ACKNOWLEDGMENT
I understand this form starts the process, that I may be asked for a
certification supporting the family member's condition or documentation of the
family relationship, and that I will receive a written notice of my eligibility
within five business days.
Employee signature: __ Date: _
SECTION 6: FOR COMPANY USE ONLY
Received: _ By: __
Eligibility confirmed: [ ] Yes [ ] No
WH-381 sent: _
Certification requested: [ ] Yes, form: _ [ ] No
Relationship documentation requested: [ ] Yes [ ] No
WH-382 designation sent: _ Outcome: _
Note: a fitness-for-duty certification may not be required for family care or
bonding leave, since it applies only to the employee's own condition.
DISCLAIMER: This is a sample template for general information only and is not
legal advice. State paid family leave programs may run alongside federal leave
with different eligibility and benefits. Have a qualified employment attorney
review before use.
Template 4: Military Family Leave
For a qualifying exigency arising from covered active duty, or military caregiver leave. Includes the exigency categories and the separate 26-workweek entitlement that applies to caregiver leave rather than the standard one.
Request Form: Military Family Leave
FMLA LEAVE REQUEST: MILITARY FAMILY LEAVE
[Company Name]
Use this version for a qualifying exigency arising from a family member's covered
active duty, or for military caregiver leave. Submit to [name or role] at [email
or location].
SECTION 1: EMPLOYEE
Name: __ Employee ID: __
Job title: __ Department: __
Supervisor: __ Date of hire: _
SECTION 2: TYPE OF MILITARY FAMILY LEAVE
•[ ] Qualifying exigency leave, arising from my [ ] spouse [ ] child [ ] parent
being on covered active duty or called to covered active duty
•[ ] Military caregiver leave, to care for a covered servicemember with a
serious injury or illness
Servicemember name: __
Relationship to me: __
Branch and unit, if known: __
SECTION 3: QUALIFYING EXIGENCY DETAIL (IF APPLICABLE)
Check the category that fits:
•[ ] Short-notice deployment
•[ ] Military events and related activities
•[ ] Childcare and school activities
•[ ] Financial and legal arrangements
•[ ] Counseling
•[ ] Rest and recuperation
•[ ] Post-deployment activities
•[ ] Care for the military member's parent
•[ ] Additional activities agreed between the employer and employee
Brief description of the activity and dates:
__
SECTION 4: LEAVE PATTERN AND ENTITLEMENT
•[ ] Continuous leave from _______________ to _______________
Template 5: Intermittent and Reduced-Schedule Request
For leave taken in separate absences or as reduced hours. Captures the expected pattern, sets the call-in procedure for unplanned absences, and covers tracking increments and temporary transfer.
Intermittent and Reduced-Schedule Leave Request
INTERMITTENT OR REDUCED-SCHEDULE LEAVE REQUEST
[Company Name]
Use this version when leave will be taken in separate blocks of time or as a
reduced schedule rather than one continuous absence. Submit to [name or role] at
[email or location].
SECTION 1: EMPLOYEE
Name: __ Employee ID: __
Job title: __ Department: __
Regular schedule: __ Hours per week: _
SECTION 2: REASON AND PATTERN
Reason for leave:
•[ ] My own serious health condition
•[ ] To care for a family member with a serious health condition
•[ ] Bonding with a new child (note: this generally requires employer agreement)
•[ ] Qualifying exigency
Requested pattern:
•[ ] Intermittent: separate absences as needed
•[ ] Reduced schedule: a consistent reduction in daily or weekly hours
Expected frequency: approximately absences per [week / month]
Expected duration of each absence: __
If reduced schedule, proposed hours: __
Expected overall period: from _ to _
SECTION 3: SCHEDULING
For planned treatment, list known appointment dates and times:
__
__
I understand that where leave is for planned medical treatment, I should consult
with [Company Name] and make a reasonable effort to schedule treatment so it does
not unduly disrupt operations, subject to the approval of my health care
provider.
SECTION 4: CALLING OUT FOR AN UNPLANNED ABSENCE
For unforeseeable intermittent absences, notify [name or role] at [phone or
method] as soon as possible and practical, following the company's usual call-in
procedure.
When you call in, please state that the absence relates to your approved
intermittent leave so it can be tracked correctly. You do not need to repeat the
underlying reason each time.
SECTION 5: TRACKING
Intermittent leave is tracked in the smallest increment the payroll system uses
for other types of leave. Time used counts against the total entitlement.
SECTION 6: ACKNOWLEDGMENT
I understand that I may be temporarily transferred to an alternative position
with equivalent pay and benefits that better accommodates a foreseeable planned
reduced schedule, and that I may be asked for recertification periodically.
WH-382 designation sent: _ Increment used for tracking:
Recertification review date: _
DISCLAIMER: This is a sample template for general information only and is not
legal advice. Intermittent leave for bonding generally requires employer
agreement, while intermittent leave for a serious health condition generally does
not. Have a qualified employment attorney review before use.
Template 6: Employer Processing Checklist
The workflow from the employer side: the coverage and eligibility test first, then the five-business-day eligibility notice, the 15-calendar-day certification window, the five-business-day designation notice, the leave itself, and the return.
Employer FMLA Request Processing Checklist
EMPLOYER FMLA REQUEST PROCESSING CHECKLIST
The deadlines below are short and they start when the request arrives, not when
you get to it. Run this every time.
STEP 0: ARE YOU EVEN COVERED?
Employer coverage. A private employer is covered if it has 50 or more employees
in 20 or more workweeks in the current or preceding calendar year.
•Employee count meets the threshold? [ ] Yes [ ] No
Employee eligibility. All three must be true:
•Employed by you for at least 12 months? [ ] Yes [ ] No
•At least 1,250 hours of service in the 12 months before the leave starts?
[ ] Yes [ ] No
•Works at a site with 50 or more employees within 75 miles? [ ] Yes [ ] No
If you are not a covered employer, federal leave does not apply, but state leave
law may. Check the rule in every state where you have employees before declining
a request.
STEP 1: RECOGNIZE THE REQUEST (DAY 0)
An employee does not have to use your form or say the words family and medical
leave. They only have to give enough information for you to know the leave may
be covered. A text message about a hospital stay can be a valid request.
•Date the request was received: _______________
•Received by: _______________________
•Logged in the leave record: [ ] Yes
Train supervisors to pass anything that sounds like a health-related absence to
[name or role] the same day. The clock runs from when the company knows, not
from when HR finds out.
STEP 2: ELIGIBILITY AND RIGHTS NOTICE (WITHIN 5 BUSINESS DAYS)
•Eligibility determination completed
•Notice of Eligibility and Rights and Responsibilities sent: _______________
•If not eligible, at least one reason stated on the notice
•Method of delivery recorded
Due date: _ (Five business days from the request, absent
extenuating circumstances.)
STEP 3: CERTIFICATION, IF YOU REQUIRE ONE (15 CALENDAR DAYS)
•Certification form provided: _______________________
•Date requested: _______________
•Due back by: _______________ (Allow at least 15 calendar days.)
•If incomplete or insufficient, state in writing what is missing and allow at
least 7 calendar days to cure: [ ] Done on _
•Received on: _______________
STEP 4: DESIGNATION NOTICE (WITHIN 5 BUSINESS DAYS)
Once you have enough information to decide:
•Designation Notice sent: _______________
•Outcome recorded: [ ] Approved [ ] Denied with reason
•Amount of leave counted against the entitlement stated, if known
•If a fitness-for-duty certification will be required on return, stated in this
notice: [ ] Yes [ ] Not required
Due date: _
STEP 5: DURING THE LEAVE
•Group health coverage maintained on the same terms
•Premium payment arrangement documented and communicated
•Leave time tracked against the entitlement in consistent increments
•Any recertification requested at permitted intervals only
•Coverage arranged as temporary, since the position must be restored
STEP 6: THE RETURN
•Return date confirmed in writing
•Fitness-for-duty certification collected, if it was required in the
designation notice
•Employee restored to the same or an equivalent position
•Benefits and seniority restored as they stood before leave
RECORDS
•Medical certifications filed separately from the personnel file, access
restricted
•Request forms, notices, and correspondence retained
•Retention period met for leave records
DISCLAIMER: This is a sample checklist for general information only and is not
legal advice. Deadlines and obligations differ under state leave laws, which may
apply to employers too small for federal coverage. Have a qualified employment
attorney review your process.
How an Employee Requests Leave
The rules on the employee side are looser than most people expect, and knowing them prevents the two most common errors: an employer waiting for paperwork that was never required, and an employee assuming a form is the only way to ask.
The first time an employee needs leave for a qualifying reason, they do not have to name the law. They must give enough information for the employer to know the leave may be covered, and they must follow the employer's usual call-in procedures for reporting an absence. Where the need is foreseeable, at least 30 days advance notice is required if possible and practical; where it is not, notice must come as soon as possible and practical. For planned medical treatment, the employee should consult with the employer and try to schedule so as not to unduly disrupt operations, subject to what their provider allows.
On a later request for the same condition, the employee does need to reference the qualifying reason or the leave specifically rather than simply calling out. And where notice is insufficient without a reasonable excuse, the employer may in some circumstances delay the start of the leave.
The Deadline Clock
Once a request lands, three deadlines run in sequence. They are the reason a company-use block belongs on the form rather than in someone's inbox.
Step
Who acts
Deadline
Document
Request received
Employee
30 days ahead if foreseeable, otherwise as soon as practical
Your intake form, or any sufficient notice
Eligibility and rights notice
Employer
Within five business days of the request
Notice of Eligibility and Rights and Responsibilities
Certification returned
Employee and provider
At least 15 calendar days from the request
The applicable certification form
Designation notice
Employer
Within five business days of having enough information
Designation Notice
Return to work
Employee
As designated
Fitness-for-duty certification, if required in the designation notice
If a certification comes back incomplete or insufficient, the employer must say in writing what is missing and allow time to fix it rather than simply denying the leave. Failure to provide the required notices can create liability for compensation and benefits lost as a result, which is why the dates belong on the form.
Four Rules That Catch Small Employers
Four points account for most of what goes wrong with leave requests at small-business scale. Each is built into the templates above.
The employee does not have to use your form, or even name the law
This is the rule that catches most small employers, because it inverts the intuition that a process starts when paperwork arrives. Under Department of Labor guidance, the first time an employee requests leave for a qualifying reason they do not have to mention the Family and Medical Leave Act at all. What they must do is provide enough information for the employer to know the leave may be covered. A text message saying a spouse is in the hospital and they will be out for a week can be a valid request. The practical consequences are two. Your form is an internal standardization tool, not a gate, so never treat a request as not made because the form was not submitted. And the deadline clock starts when the company learns of the need, which includes a supervisor being told, not when HR is eventually looped in. Train supervisors to escalate anything that sounds health-related the same day. This is general information, not legal advice.
Five business days, fifteen calendar days, five business days
Three deadlines govern the process and each is short enough to miss while doing something else. First, once an employee requests leave, the employer must notify them of their eligibility within five business days, absent extenuating circumstances, using the Notice of Eligibility and Rights and Responsibilities or an equivalent. Second, where the employer requests a certification, the employee must be allowed at least 15 calendar days to return it. Third, once the employer has enough information to determine that the leave qualifies, it must provide a written designation notice within five business days. Missing these is not a technicality: failure to give required notices can result in liability for compensation and benefits lost as a result. Put the dates on the form itself, which is why every template here has a company-use block that captures them. This is general information, not legal advice.
Check coverage before you check anything else
Many small businesses assume the federal law applies to them and it often does not. A private employer is covered only if it has 50 or more employees in 20 or more workweeks in the current or preceding calendar year. Separately, an employee is eligible only if they have worked for the employer for at least 12 months, have at least 1,250 hours of service in the 12 months before the leave begins, and work at a site where the employer has at least 50 employees within 75 miles. All three employee conditions must be met. For a business in the 5 to 50 employee range, the honest answer is frequently that federal leave does not apply. That is not the end of the analysis, though, because a number of states run their own leave programs with lower employer thresholds and different eligibility rules, and those can apply where the federal law does not. Check the state rule before declining a request. This is general information, not legal advice.
Your intake form is not a substitute for the official notices
There is no official government intake or request form, which is exactly why template pages like this one exist. What the Department of Labor does publish is a set of free, optional-use forms covering the other side of the process: the employer's Notice of Eligibility and Rights and Responsibilities, the Designation Notice, and certifications completed by a health care provider for the employee's own condition, a family member's condition, a qualifying exigency, and a servicemember's serious injury or illness. Employers may use their own versions provided they contain the same basic information, but for a small business there is little upside in rewriting them. The sensible arrangement is to use your own intake form as the front end, because none is provided, and use the official forms for the notices and certifications, because they already meet the content requirements and cost nothing. This is general information, not legal advice.
The Three Deadlines, In Order
Once a request arrives: the eligibility and rights notice is due within five business days, a requested certification must allow the employee at least 15 calendar days to return it, and the written designation notice is due within five business days of having enough information to decide. The Department of Labor publishes the employer notification requirements in full. Failure to give required notices can create liability for compensation and benefits lost as a result. This is general information, not legal advice.
The Department of Labor publishes free, optional-use forms as electronically fillable PDFs. Notably, none of them is a request or intake form, which is the gap the templates on this page fill.
Document
Who completes it
When
Leave request form
Employee
At the start; no official version exists, so you supply one
Notice of Eligibility and Rights and Responsibilities
Employer
Within five business days of the request
Certification of a health care provider
Health care provider
Returned by the employee within at least 15 calendar days
Certification of qualifying exigency
Employee, with supporting documentation
For military family leave
Certification for a servicemember
Health care provider
For military caregiver leave
Designation Notice
Employer
Within five business days of having enough information
The sensible division of labor for a small business is straightforward. Use your own intake form at the front, because none is provided. Use the official notices and certifications for everything after it, because they are free and already contain the required content, and rewriting them adds legal risk for no benefit. Employers may use their own versions provided they capture the same basic information, but there is rarely a reason to.
Receive, Notify, and Track
A downloaded form is the starting point, and these work on their own. The strain shows up in the timing and the trail: a request mentioned to a supervisor and passed along a week later, an eligibility notice that went out on day nine, a certification nobody chased, and no single place showing how much entitlement is left.
Log the request the day it arrives
Record the date the company learned of the need, whether it came on your form, by email, or by a phone call to a supervisor. The clock starts there.
Run the eligibility test
Check employer coverage and the three employee conditions before anything else, and note the result on the form so the reasoning is on record.
Send the notices on schedule
Eligibility and rights notice within five business days, certification with at least 15 calendar days to return it, designation notice within five business days of deciding.
Track the leave and file the records
Count leave against the entitlement in consistent increments, keep medical certifications separate from the personnel file, and retain the full set.
To run that without a spreadsheet, FirstHR stores the request, the notices, and the certification against the employee record, keeps medical documents access-controlled and separate from the general personnel file, tracks which documents are outstanding and when each notice is due, and captures signatures with e-signature so the timeline is documented rather than reconstructed. FirstHR is an onboarding and HR platform, not a law firm or a leave administrator: it does not determine eligibility, calculate entitlement, or decide whether a leave qualifies, so pair it with a qualified employment attorney for those calls. Applicant tracking is coming soon to FirstHR.
Key Takeaways
An FMLA request form is an internal intake document; no official government version exists, which is why employers create their own.
An employee does not have to use your form or name the law, and only has to give enough information for you to know the leave may be covered.
The employer must send the eligibility and rights notice within five business days, allow at least 15 calendar days for certification, and issue the designation notice within five business days of deciding.
Coverage is not automatic: the employer threshold is 50 or more employees, and the employee must have 12 months of service, 1,250 hours, and 50 employees within 75 miles.
Keep diagnosis details off the intake form; medical information belongs on the certification and must be filed separately from the personnel record.
Use your own form at the front of the process and the free official forms for the notices and certifications that follow. This is general information, not legal advice.
Frequently Asked Questions
What is an FMLA request form?
An FMLA request form is an internal intake document an employee completes to tell their employer they need leave under the Family and Medical Leave Act. It typically captures the employee's name and position, the qualifying reason by checkbox, whether the leave will be continuous or intermittent, the requested dates, whether accrued paid leave should run alongside it, and a signature, followed by a company-use section recording the eligibility determination and the notice dates. It is worth understanding what it is not. There is no official government request form, so this document is one you create. It is not the medical certification, which a health care provider completes. And it is not an approval, since the employer still has to determine eligibility and issue the required notices. This is general information, not legal advice.
Is an employee required to use the employer's FMLA request form?
No. Under Department of Labor guidance, the first time an employee requests leave for a qualifying reason, they do not have to mention the Family and Medical Leave Act at all. What they must do is provide enough information for the employer to know that the leave may be covered. An employee may also be required to follow the employer's usual and customary call-in procedures for reporting an absence. The practical implication for an employer is important: you cannot treat a request as not made because someone did not fill in your form. If an employee tells a supervisor they are having surgery next month and will be out for six weeks, that is a request, and the deadline clock starts. Your form is a standardization tool that makes sure you capture the same information every time and respond on schedule, not a gate that controls whether the process begins. This is general information, not legal advice.
Does the FMLA apply to small businesses?
Often not, and it is worth checking before anything else. A private employer is covered only if it has 50 or more employees in 20 or more workweeks in the current or preceding calendar year. Separately, an individual employee is eligible only if all three of the following are true: they have worked for the employer for at least 12 months, they have at least 1,250 hours of service in the 12 months before the leave begins, and they work at a site where the employer has at least 50 employees within 75 miles. A business with 30 employees at one location is generally not a covered employer under the federal law. That does not end the analysis, though. A number of states operate their own family and medical leave programs, some with much lower employer thresholds, and those can apply where the federal law does not. Check the state rule for every state where you have employees before declining a request. This is general information, not legal advice.
How much notice does an employee have to give?
It depends on whether the need for leave is foreseeable. When the employee knows about the need in advance, such as a surgery scheduled two months out, they must give at least 30 days advance notice if it is possible and practical to do so. When 30 days is not possible, because circumstances changed, because the timing was not known, or because of a medical emergency, notice must be given as soon as possible and practical under the circumstances. For a qualifying exigency arising from military duty, notice must be given as soon as possible and practical regardless of how far in advance the leave is needed. Where leave is for planned medical treatment, the employee should consult with the employer and make a reasonable effort to schedule treatment so it does not unduly disrupt operations, subject to the health care provider's approval. Where an employee gives insufficient notice without a reasonable excuse, the employer may in some circumstances delay the leave. This is general information, not legal advice.
What are the employer deadlines after receiving a request?
Three deadlines matter and all of them are short. First, once an employee requests leave, the employer must notify them of their eligibility within five business days, absent extenuating circumstances, and provide the accompanying rights and responsibilities information in writing. Second, if the employer requests a certification, the employee must be allowed at least 15 calendar days to return it, with additional time where it is not feasible despite the employee's diligent good-faith efforts. Third, once the employer has enough information to determine that the leave qualifies, it must provide a written designation notice within five business days. If a certification comes back incomplete or insufficient, the employer must state in writing what additional information is needed and allow time to cure. Failing to provide required notices can create liability for compensation and benefits lost as a result, so these dates belong on the form itself. This is general information, not legal advice.
What is the difference between a request form and the official DOL forms?
They sit at different points in the process and are completed by different people. The request form is the front end: an internal intake document the employee gives you to start the process, and no official version exists, which is why employers create their own. The official optional-use forms cover what comes next. The Notice of Eligibility and Rights and Responsibilities and the Designation Notice are employer-to-employee notices. The certification forms are completed by a health care provider and cover the employee's own serious health condition, a family member's serious health condition, a qualifying exigency, or a servicemember's serious injury or illness. Employers may use their own versions of the official forms provided they capture the same basic information, but for a small business there is little benefit in rewriting documents that are free and already meet the requirements. Use your own intake form, and the official forms for everything after it. This is general information, not legal advice.
Can an employee take FMLA leave intermittently?
Yes in most cases, with one significant exception. Leave for the employee's own serious health condition or to care for a family member with a serious health condition may generally be taken intermittently or on a reduced schedule when it is medically necessary. Qualifying exigency leave may also be taken intermittently. Bonding leave following a birth, adoption, or foster placement is different: taking it intermittently or on a reduced schedule generally requires the employer's agreement rather than being an entitlement. A few practical points for administering intermittent leave. Leave is counted against the entitlement in the increments the payroll system uses for other leave types. Where the need is for planned treatment on a foreseeable reduced schedule, the employee may be temporarily transferred to an alternative position with equivalent pay and benefits that better accommodates the schedule. And recertification may be requested at permitted intervals. This is general information, not legal advice.
Should the request form ask for medical details?
No, and this is a design point worth being deliberate about. The intake form should capture the category of the qualifying reason, such as the employee's own serious health condition or care for a parent, and nothing about diagnosis or treatment. Medical information belongs on the certification, which a health care provider completes and which is subject to its own rules about scope. There are three reasons to keep the intake form clean. The medical detail is not yours to collect at this stage. Any medical documentation you do receive must be kept in a confidential file separate from the general personnel record, so collecting it on a general intake form creates a filing problem. And a form that asks for a diagnosis invites employees to disclose more than the law entitles you to know, which creates its own exposure. Ask what category, not what condition. This is general information, not legal advice.
