Human Resources

Request for FMLA

The Family and Medical Leave Act of 1993 (FMLA) allows eligible employees to take job-protected, unpaid leave, or to substitute appropriate paid leave if the employee has earned or accrued it, for up to a total of 12 workweeks in a 12 month period for qualifying reasons. Qualifying reasons are listed below. Employees on FMLA are responsible for maintaining premium payments to their pension and insurance during the leave period.

The employee has the right to return to the same position or an equivalent position with equivalent pay, benefits, and working conditions at the conclusion of the leave. The taking of FMLA leave cannot result in the loss of any benefit that accrued prior to the start of the leave.

You are eligible for leave (either paid or unpaid) under FMLA if you:

NOTE: Time in the military service covered under the Uniformed Services Employment and Reemployment Rights Act (USERRA) will count towards fulfilling the length of employment and hours of work requirements to be eligible for an FMLA leave. The 7-year break in service rule does not apply to military service.

Qualifying reasons for FMLA are:

Employees are responsible for:

NOTE: Employees out on Worker’ Compensation are not required to provide the DOL Certification Form. The DWC forms that are provided are adequate documentation for verification purposes.

If further information is needed visit the US Department of Labor FMLA website:


Request for FMLA - Form
FMLA Medical Certification (DOL) Form - Employee
FMLA Medical Certification (DOL) Form - Dependent
FMLA Medical Certification (DOL) Form - Military Caregiver
FMLA Medical Certification (DOL) Form - Veteran Military Caregiver
FMLA Medical Certification (DOL) Form - Military Qualifying Exigency
Adult Child Questionnaire
Employee Rights and Responsibility Notice
Employee Rights and Responsibility Notice - Spanish
Expanded FMLA Flowchart
Expanded FMLA Request Form
Expanded FMLA Information Poster