Sample Fmla Leave Request Letter Template printable pdf download

DIRECT LINE:

866-THE-CLRC

(866-843-2572)

ONLINE INTAKE FORM :

EMAIL:

Fax : 213-736-1428

Video Relay Phone : 213-908-1079

Your Right to Take Time off from Work

The Family and Medical Leave Act (FMLA) gives eligible employees the right to take up to 12

weeks of unpaid, job and benefit-protected leave of absence from work in a 12-month period.

Please check your state’s laws for additional protections, as some states have set more

expansive medical leave standards.

Is my employer covered by the Family and Medical Leave Act?

• All public employers, and private employers with 50 or more employees within a 75-mile

radius are covered by the FMLA.

Am I protected by the FMLA?

• You are protected by the FMLA if your employer is covered, AND if you have worked for

that employer for at least one year in the past seven and for at least 1,250 hours in the last

year.

When can I take FMLA leave?

• You can take time off to take care of your own serious health condition, OR

• You can take time off to care for your spouse (including same-sex marriages), child, or

parent’s serious health condition.

What are my rights if I am covered by the FMLA?

• If you and your employer are both covered by the FMLA, you are entitled to up to 12 weeks

of unpaid leave from your job. During that time, your employer must hold your job open

for you and must maintain your benefits (like health insurance) while you are out on leave.

How do I prove to my employer that I need to take time off?

When you ask to take time off from work, you do not have to mention the FMLA by name.

However, your employer CAN require you to provide some sort of documentation or certification

from your health care provider showing the need to take time off. Your employer has to give you

at least 15 days to get the medical certification from your doctor or other health care provider.

What do I have to include in the medical certification?

• Your employer might give you a form that you will need to fill out with the help of your

doctor or another health care provider. Usually, there is a section for the employer to fill

out, another section for you to fill out, and the rest of the form is completed by your health

care provider.

• Your doctor should fill out the form to include the date that your serious medical condition

began, how long the condition will probably last, and a statement about how your serious

health condition is preventing you from doing your job. (See our “Medical Certification for

the FMLA and ADA” handout).

• If your employer did not give you a form for your doctor to fill out, you can simply have your

Sample Fmla Leave Request Letter Template