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Request for family medical leave form

Medical leave - The law Offices of Usmaan Sleemi

The Family and Medical Leave Act (FMLA) was signed into the constitution back in February 1993 by President Clinton. This act gives all eligible employees the right to take a protected leave of absence from work due to specific medical and family reasons. While some people may be aware of their eligibility, there is still the important question of how do I request for family medical leave form. Read on to find out.

Qualifications for the Family Medical Leave Act

Some of the most common qualifications for the FMLA is that you should work in a public company with more than 50 employees, or a secondary or private elementary school. You are also required to have worked for the company for at least a year, 50% of your scheduled time, and 1,250 hours in the previous year. You are a suitable candidate for the FMLA if you need time off duty to:

  • Care for an immediate family member, like a parent, child, or spouse with a chronic illness
  • Seek medical treatment for a serious health condition
  • Bond with a newly-adopted or newborn child
  • Provide foster care

How the Family Medical Leave Act Works

The United States Department of Labor’s Wage and Hour Division (DOL-WHD) has designated seven different FMLA application forms for each qualified off-duty leave. Below are some brief descriptions of the various application forms:

  1. FMLA Form WH-380-E for Employee Health Condition

This form is usually used by your employer to obtain a valid medical certification of your need to take a leave of absence from your job due to a serious health condition. It covers the following information:

  • When the health condition began
  • Its duration
  • Whether the condition required an overnight admission to a medical center
  • How it hinders your job productivity
  • The time needed off-duty
  • Your diagnosis, symptoms, and treatments
  1. FMLA Form WH-380-F for Family Health Condition

This form is used to inform your employer that you need to take time off work to care for a seriously injured or ill family member. It covers the following information:

  • When the condition began
  • How long it is expected to last
  • The type of care your affected family member needs
  1. FMLA Form WH-381 Eligibility and Rights

This is a notification document that confirms the information you gave your employee, including the reasons and dates for your absence of leave. It covers the following information:

  • The need to take leave
  • Proof of your relationship to the affected family member
  • Document military family leave
  1. FMLA Form WH-382 Designation Notice

This form is used by your employee to seek additional information as to whether your absence of work request is valid.

  1. FMLA Form WH-384 for Military Family Leave

This form is used to prove your need to take time off duty under the FMLA’s special provision for military service members and their families.

  1. FMLA Form WH-385 for Service Member Care

This form is used to request leave to take care of an injured or sick service member. Here, you will need to provide details on your relationship with the said person.

  1. FMLA Form WH-385-V for Veteran Caregiver Leave

This form is used if you want to take leave to care for a veteran who is seriously injured or ill and requires your care.


The Law Office of Usmaan Sleemi is dedicated to protecting the rights of employees in New Jersey. If you believe you are treated unfairly at work or have questions concerning how to request for family medical leave form, contact us at (973) 354-2788.