Fmla Leave Form PDF Details

The FMLA Leave Form is a document that employers and employees use to certify leave taken for family and medical reasons. The form must be completed by both the employee and the employer, and it must be filed with the Department of Labor. The purpose of this form is to ensure that employees are taking the appropriate amount of leave for legitimate reasons. Any questions about the FMLA Leave Form can be directed to the Department of Labor.

Here is the information concerning the file you were seeking to fill out. It will show you the time it should take to complete fmla leave form, exactly what fields you will need to fill in and a few additional specific facts.

Form NameFmla Leave Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesemployee sample filled fmla form, fmla request form template, fmla employee request form, fmla forms 2021 printable

Form Preview Example


(The following request is to be completed and returned to the Human Resource Office)


Employee’s Name

Employee’s Department


Request for Full-Time Leave



I request a leave of absence from

(date) to


for the following reason:

For birth of my child and/or to care for the newborn child.

For placement of a child with me for adoption or foster care.

To care for my (circle one): spouse, child or parent with a serious health condition. Name:

My own serious health condition.

For another reason. (Please specify):

Request for Intermittent or Reduced-Schedule Leave

I request intermittent leave or reduced-schedule leave at the following times:



Substitution of Paid Leave

I request to use (check all that apply):

Paid Vacation

Sick Hours

Location During Leave



I can be reached at the following address and phone number during my leave:

Employee Signature

Approved By


© The Personnel Advisor


How to Edit Fmla Leave Form Online for Free

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fmla request form fields to fill out

In the field I request intermittent leave or, Schedule, Reason, Substitution of Paid Leave, I request to use check all that, Paid Vacation, Sick Hours, Other, Location During Leave, I can be reached at the following, Employee Signature, Approved By, Date, and The Personnel Advisor type in the information which the system requires you to do.

Completing fmla request form part 2

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