Employee request for FMLA-qualifying leave with employer designation notice. Covers all qualifying reasons, required certification, and leave period calculation.
The FMLA Leave Request & Designation is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 30 days after it is sent if left unsigned. It covers fmla, leave, hr. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# FMLA Leave Request & Designation **Employer Name:** ___________ **Employee Name:** ___________ **Employee ID / Personnel Number:** ___________ **Department:** ___________ **Job Title:** ___________ **Work Location:** ___________ **Date of Request:** ___________ --- ## Part A — Employee Request ### 1. Leave Reason I am requesting leave under the Family and Medical Leave Act of 1993 (29 U.S.C. § 2601 et seq.) and applicable regulations (29 C.F.R. Part 825) for the following qualifying reason: ___________ **Describe the need for leave (do not include confidential medical details — a general description is sufficient):** ___________ **Name of family member requiring care (if applicable):** ___________ **Relationship to family member (if applicable):** ___________ ### 2. Requested Leave Dates **Type of leave needed:**