FMLA Request Form Template for Small Business

An FMLA request form is where an employee's request for leave under the Family and Medical Leave Act gets written down: who needs the time, why, and when. It starts a process with unforgiving deadlines, and below are six free versions to download. My advice to another founder: log every leave request the day anyone in the company hears it, form or no form.

The Department of Labor (DOL) publishes official forms for the notices you send and for the certifications, most of them completed by a health care provider. Nothing official exists for the request itself, which is why every employer ends up building or borrowing one.

The six templates are 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 with no email required.

Each template 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.

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.

Are You Even Covered?

Not necessarily, and for a small business it is the first thing worth checking, even though most template pages skip it. Under the statute's definitions, coverage has two layers: whether you are a covered employer, and whether the individual employee is eligible. Both have to be satisfied.

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.

Federal coverage 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.

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.

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.

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.

Template 2: Own Serious Health Condition

Tuned for the most common case. According to the Department of Labor's 2018 FMLA Employee Survey, 51% of family and medical leaves were for the employee's own illness, more than for any other reason.

This version 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.

Template 3: Family Care and Bonding Leave

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.

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.

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.

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.

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.

Under the employee notice regulation, 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 the treatment so it does not 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.

Requesting an Extension of Leave

There is no separate government extension form. When an employee needs more time than the dates on the original request, the same intake form does the job: mark it as an update to an existing leave, write in the revised return date, and log the day it arrived the way you logged the first one.

An extension stays protected only while entitlement remains, so check the balance before you answer. The federal entitlement is 12 workweeks of unpaid leave in a 12 month period, per the Department of Labor, with 26 workweeks for military caregiver leave. Where a leave is extended, recertification may be requested sooner than the usual intervals.

When the balance runs out mid-leave, the decision moves to company policy and whatever else applies, and it belongs in writing rather than in a hallway conversation. An exhaustion letter is the usual way to close that loop. This is general information, not legal advice.

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.

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.

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.

How This Fits the Official Forms

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.

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.

Getting the Forms as PDFs

Every official form is published as an electronically fillable PDF, and each one carries a form number. WH-381 is the eligibility and rights notice, WH-382 is the designation notice, and the certifications run from WH-380-E through WH-385-V depending on the reason for the leave. All of them come from the Department of Labor forms page linked above.

The request forms on this page are Word documents rather than PDFs, on purpose, because your company name, your contact, and your deadlines have to go into them before anyone fills one in. Once yours is edited, open the File menu, then choose Save As and pick PDF as the format.

Keep the Word file as the master and hand out the PDF. That way the next request starts from the current version instead of from a copy someone marked up during the last leave, and the employee gets a document that cannot be altered by accident on the way back.

Which Certification Form to Send

Which FMLA certification form you send depends on the reason for the leave, and there is one for each reason except bonding with a new child. Requesting a certification is a choice rather than an obligation, and it happens after the request arrives, not as part of it. The employee never completes the medical portion.

The certification regulation sets the timing: allow at least 15 calendar days for the form to come back, and more where the employee's diligent, good-faith efforts still fall short. If it returns incomplete (entries left blank) or insufficient (answers that are vague or non-responsive), say in writing what is missing and allow seven calendar days in most circumstances to fix it.

Two limits trip employers up. Contact with the provider may only authenticate or clarify what is already on the form, and it has to come from someone other than the employee's direct supervisor. Where you genuinely doubt a certification, you may require a second opinion, and a third if the two disagree, both at the employer's expense.

Recertification runs on a schedule too. The general rule is no more often than every 30 days, and only in connection with an absence. Where the certification gives a minimum duration longer than 30 days, you generally wait until that period ends, but in all cases you may ask for recertification every six months in connection with an absence. You may ask sooner when the employee requests an extension, circumstances change significantly, or you receive information casting doubt on the stated reason. The Department of Labor publishes the full rules.

Once you have what you need, the designation notice is the next document out the door. This is general information, not legal advice.

Receive, Notify, and Track

A downloaded form is the starting point, and the templates here 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.

To run that without a spreadsheet, FirstHR stores the signed request and the notices in the employee's file, lets you give each notice a task with a deadline, and collects the employee's signed acknowledgments with e-signature, so the timeline is documented rather than reconstructed. The medical certification itself belongs in a separate confidential file, not in the general personnel file.

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.

Whichever way you run it, the first step is the same: download the general form, add your company name and contact, and make sure every supervisor knows to pass a leave request along the day they hear it.

Frequently Asked Questions