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How to Fill Out the Family Medical Leave Act Form

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The Family Medical Leave Act, or FMLA, requires many employers to allow qualifying employees up to 12 weeks leave due to personal illness, pregnancy and birth of a child, adoption of a child or need to care for a family member with a serious illness. To qualify for FMLA, employees must have worked for their employers for at least 12 months and must have worked at least 1,250 hours in the past 12 months. Employers with fewer than 50 employees do not have to allow employees to take Family and Medical Leave.

Request a Family Medical Leave Act form from your employer. The United States Department of Labor offers a form that employers may use if they like but it is not required. Employers may design their own forms if they prefer but they cannot ask for more information than that requested on the form from the Department of Labor.

Look at the form to see if your employer completed the first section of the form. If not, ask your employer to do so.

Print your full name in section two of the form.

Give the form to your health care provider to complete, certifying that you need to take family medical leave. Provide your health care provider with a copy of your job description or simply describe your job duties so that he can accurately complete the form.

Review the form after your health care provider has completed section three to make sure it has been completed fully and accurately. Discuss any discrepancies or concerns with your health care provider.


Some health care providers charge patients a fee for completing paperwork such as the Family Medical Leave Act form. Call your health care provider’s office to find out if you will need to pay a fee when you drop off the form to be completed or when you pick up the completed form.


By law, your employer must give you 15 days to complete the FMLA form. Make sure you return the form to your employer in no more than 15 days or your employer can refuse to grant you leave.