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Request for Family and Medical Leave Form

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

When to Use

An employee who requests leave under the Family and Medical Leave Act (FMLA) may be required to provide written notice of the reasons for the leave, the anticipated duration of the leave and the anticipated start of the leave. The form below can be used to obtain this information. The FMLA requires that notice be provided at least 30 days in advance if the need for leave is foreseeable or, in the case of an unforeseeable absence, as soon as practicable.

Customizable Form