Family Medical Leave Act (FMLA) Application Form - Employee and Health Care Provider Instructions

Sep 19, 2026

Family Medical Leave Act (FMLA) application form for requesting leave based on an employee’s serious medical condition. The employee authorizes a licensed health care provider to complete the form and submit it to District 120 Human Resources. The form collects details about the medical condition, hospitalization, treatment dates, expected duration, pregnancy status, essential job function limitations, incapacity periods, and follow-up needs, while instructing providers to avoid genetic information under the Genetic Information Nondiscrimination Act. Fax submission instructions are included.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

To be completed by employee

Instructions for the Health Care Provider

To be completed by the health care provider

Submission instructions

Family Medical Leave Act (FMLA) Application Form To be completed by you and a licensed health care provider describing the employee’s medical condition for the purpose of determining eligibility for leave under the Family Medical Leave Act. TO BE COMPLETED BY EMPLOYEE I authorize my medical provider(s) to complete this form based on information from my patient file and provide this form to the District 120 Human Resources Director. First Name: Middle Initial: Last Name: Signature: Date: Instructions for the Health Care Provider Your patient is requesting leave under the Family Medical Leave Act. Please answer, fully and completely all applicable parts of this form. Several questions seek a response as to the frequency or duration of a condition, treatment plan, etc. Your answers should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Please be as specific as possible and limit your response to the condition for which the employee is seeking leave. When applicable, circle YES or NO to indicate your response. The Genetic Information Nondiscrimination Act of 2008 prohibits employers from requesting or requiring genetic information of an individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information” as defined by this law, includes an individual’s family medical history, results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. TO BE COMPLETED BY THE HEALTH CARE PROVIDER Provider’s Name: Provider’s Business Address: Type of Practice/Medical Specialty: Telephone: ( ) Fax: ( ) When did the medical condition(s) begin? How long is the condition expected to last? If the condition is permanent, please indicate. Was the patient admitted for an overnight stay in a hospital or residential medical care facility? If yes, what were the dates of admission? What were the dates in which you treated the patient for this condition? Will the patient require treatment at least twice per year due to the condition? YES or NO Was medication, other than over-the-counter medication prescribed? YES or NO Was the patient referred to other health care providers for evaluation or treatment? If yes, please state the nature of the treatments and expected duration of treatment. Is the medical condition pregnancy? YES or NO If yes, expected delivery date: Has the patient provided you with their job description? YES or NO If no, please answer these questions based upon the patient’s own description of their essential job functions. Is the patient unable to perform any of their essential job functions due to the condition? YES or NO If yes, identify the job functions the employee is unable to perform. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave. Will the patient be incapacitated for a single continuous period of time due to this condition, including any time for treatment and recovery? YES or NO If yes, estimate the beginning and ending dates for the period of incapacity: Will the patient require follow-up treatment appointments or work part-time/reduced schedule because of the condition? YES or NO If yes, are the treatments or reduced number of hours worked medically necessary? YES or NO Please list the estimated treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Estimated part-time/reduced work schedule the employee needs, if a

FAQs

What is the purpose of this FMLA application form?

It is used to describe the employee’s medical condition so the employer can determine eligibility for leave under the Family Medical Leave Act.

What does the employee need to do on the form?

The employee provides authorization for the medical provider(s) to complete the form using information from the patient’s file and to submit it to the District 120 Human Resources Director.

What information must the health care provider provide?

The provider must enter practice and provider details and answer questions about when the condition began, expected duration, hospitalization and treatment dates, whether the patient requires treatment at least twice per year, job function limitations, incapacity dates, follow-up needs, and episodic flare-ups.

Sep 19, 2026

Upload by Taylor Morgan