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Request for Family and Medical Leave Form

Author: Barton A. Bixenstine, Vorys, Sater, Seymour and Pease LLP

When to Use This Form

The Family and Medical Act regulations provided that "an employer may require that an employee provide written notice set[ting] forth the reasons for the requested leave, the anticipated duration of the leave, and the anticipated start of the leave." The form below can be used to obtain this information either before the leave begins or, in the case of an unforeseeable absence, as soon as practicable after the absence begins.

Customizable Form