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Family and Medical Leave Form

Free family and medical leave request form template for an employee to request job-protected leave for a serious health condition or family need.

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This free family and medical leave form covers Reason for Leave, Requested Dates, Certification, Employer Use Only with 5 clearly marked [placeholder] fields to fill in — built for small business owners and first-time managers handling an HR moment professionally without a dedicated HR department to lean on. Copy it into your own word processor, fill in the placeholders, and review it — or adapt it — before use. It's part of docstoc's free document template library, alongside business, legal, real estate, finance, and HR templates. Every template here is free to copy with no signup required, and each one carries a plain disclaimer: this is a starting point for informational purposes, not a substitute for advice from a licensed professional in your jurisdiction.

Template — click to edit

Family and Medical Leave Request

Employee: [Name] · Department: [Department] · Date of Request: [Date]

Reason for Leave

[ ] Employee's own serious health condition [ ] Care for a spouse, child, or parent with a serious health condition [ ] Birth/adoption/foster placement of a child [ ] Qualifying military family leave reason [ ] Other (specify): ______

Requested Dates

Start date: [Date] · Expected end date: [Date] · [ ] Continuous leave [ ] Intermittent leave (describe schedule): ______

Certification

[ ] Medical certification attached/will be provided within [Number] days.

Employer Use Only

Item	Details
Eligibility confirmed (12 months employed, 1,250 hours)	[ ] Yes [ ] No
Leave designated as FMLA/state equivalent	[ ] Yes [ ] No
Benefits continuation during leave	[Details]
Job restoration confirmed upon return	[ ] Yes

Employee signature: ______________________ Date: ____________ HR representative: ______________________ Date: ____________

*This document is provided for informational and educational purposes only and does not constitute legal advice. FMLA eligibility has specific thresholds (12 months of employment, 1,250 hours worked, and employer size of 50+ employees within 75 miles) — many states also have their own family/medical leave laws with different, sometimes more generous, requirements that may apply even when FMLA doesn't.*

Edit directly in the box above. Download PDF anytime — the docstoc.io footer is always included and cannot be removed.

What's included

Edit online — click the document, fill in placeholders, download a PDF
4 standard sections: Reason for Leave, Requested Dates, Certification, Employer Use Only
5 clearly marked [placeholder] fields for quick personalizing
Free to use — no account or signup required
Fully editable — adjust any clause to match your actual situation
Includes a signature block, ready to print or sign digitally
Fixed docstoc.io footer on every PDF (not removable)

Who this template is for

Freelancers & solo founders

Handling routine business paperwork without commissioning custom legal drafting for every document.

Small businesses

Standardizing recurring documents — leases, agreements, notices — across a growing operation.

Anyone reviewing before signing

Using a clear starting structure to understand what a document should cover, even if a lawyer finalizes it.

Growing teams

Formalizing hiring and performance processes as a company adds its first employees.

FAQ

Is this family and medical leave form template really free?

Yes. Like every template in docstoc's library, this family and medical leave form is free to use, with no account or signup needed to view, edit, or download it.

What does this family and medical leave form cover?

This hr template includes Reason for Leave, Requested Dates, Certification, Employer Use Only. Fill in the [bracketed] placeholders, edit any clause online, then download a PDF — the docstoc.io footer stays on every export.

Is this legal advice?

No. Employment documents sit on top of a mix of federal, state, and sometimes city labor law — at-will employment rules, required notices, and what you can and can't put in writing all vary. Have an employment attorney or HR professional confirm this fits your jurisdiction before you use it.

Can I edit the wording?

Yes — edit directly on the page, adjust any section or clause, and re-fill the 5 placeholder fields to match your situation before downloading a PDF. It's a starting structure, not a rigid script.

Where can I find more free templates like this?

Browse more free hr and related document templates in the docstoc library at /document-templates/.

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