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FMLA Leave Request

FMLA leave request — qualifying event, duration, WH-380 medical certification routing.

Start free — included with every suite See it in MangoApps

14 days free, $0 today — Forms comes with every suite.

Rolled out to every employee at AutoZone (125,000), PetSmart (50,000+), A.S. Watson and Raley's (20,000) — and at larger retailers we are not permitted to name.

Built for: All FMLA-covered employers

What's inside this template

Employee

  • Employee name (required)
  • Department / manager (required)
  • Date of hire (required)

    Used to verify 12-month / 1,250 hour eligibility

Leave Details

  • Reason for leave (required)

    Own serious health / Family member care / Birth / Adoption / Military exigency / Military caregiver

  • Expected start date (required)
  • Expected end date (required)
  • Continuous, intermittent, or reduced schedule? (required)

Certification

  • Healthcare provider certification (WH-380) attached
  • Upload WH-380 (within 15 days of request)

Sign-Off

  • Employee signature (required)

Common use cases

FMLA-qualifying leave request

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Ready to use this template?

FMLA Leave Request runs on a platform app included with every MangoApps plan — pick a suite and it comes along.

Start free — included with every suite

Rolled out to every employee at AutoZone (125,000), PetSmart (50,000+), A.S. Watson and Raley's (20,000) — and at larger retailers we are not permitted to name.