FAMILY MEDICAL LEAVE (FMLA) APPLICATION FORM - Section A - To Be Completed by Employee - Initials and Certification

Sep 19, 2026

Family Medical Leave (FMLA) Application Form for employees to request eligible family and medical leave by providing employee and patient information, leave date ranges, and whether intermittent leave is requested. The form requires a detailed reason for leave, including caregiver relationship explanations when applicable, and includes employee acknowledgments with initial fields. Employees must complete certification, provide signature and date, and submit the completed form with supporting documentation to the RISD Human Resources Department, following specified timelines for submissions and possible fitness-for-duty documentation.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Section A – To Be Completed by Employee

Employee Information

Patient Information

Leave Request Information

Reason for Leave

Employee Acknowledgments

Employee Certification

Submission Instructions

FAMILY MEDICAL LEAVE ( FMLA) APPLICATION FORM | SECTION A – TO BE COMPLETED BY EMPLOYEE
Employee Name ( First, MI, Last): Employee ID: Employee Phone Number: Home: Cell: Employee Personal Email Address ( Non-District): Employee Home Street Address: City: State: Zip Code: | | --- | | Patient Information
Patient’s Relationship to Employee:
☐ Self ☐ Spouse ☐ Same-Gender Spouse ☐ Parent ☐ Child ☐ Domestic or Civil Union Partner ☐ Other:
If Child, Child’s Birth Date: | Leave Request Information Requested Leave Dates ( MM/ DD/YYYY to MM/ DD/YYYY) : Last Day Worked: Intermittent Leave Requested: ☐ Yes ☐ No Reason for Leave ( If leave is for a family member, explain the care you will provide. If in loco parentis status applies, explain your relationship to the individual needing care. In loco parentis refers to a person who has day-to-day responsibility to care for and financially support a child, or who had such responsibility for the employee when the employee was a child. ) Employee Acknowledgments Please read and initial each statement below: ☐ I have received and read the Family and Medical Leave Act ( FMLA) Notice included with this document. ☐ I have read and understand RISD policies related to family and medical leave. ☐ I understand that I have 15 calendar days to submit all required supporting documentation for my FMLA request. ☐ I understand that failure to complete or submit required forms within the specified timelines may result in denial of leave and/or discontinuation of pay. ☐ I understand that a Fitness for Duty Certification, if applicable, including job restrictions or accommodation requests, must be submitted to RISD prior to my return to work. ☐ I understand that failure to return to work as scheduled or to keep my Supervisor, RISD Human Resources, and Leave Administration informed of my status may be considered job abandonment and could result in termination of employment. ☐ I authorize RISD Human Resources to contact my healthcare provider, or my family member’s healthcare provider, for purposes of clarification and authentication of medical certification, if applicable. ☐ I understand that any supplemental leave programs offered by RISD are separate from FMLA and may have additional eligibility and submission requirements. Employee Certification I certify that the information provided above is complete and accurate to the best of my knowledge. Employee Signature: Date: Submit completed form and supporting documentation to: RISD Human Resources Department

FAQs

What employee information is required in Section A?

The form collects employee name, employee ID, phone numbers (home/cell), non-district personal email, and home street address with city, state, and ZIP code.

What must be provided under leave request information?

Employees must enter the requested leave date range, the last day worked, indicate whether intermittent leave is requested, and provide a reason for the leave including the care relationship when relevant.

What acknowledgments must employees complete before submitting?

Employees must read and initial statements covering receipt of the FMLA Notice, understanding of RISD policies, submission timelines for supporting documentation, consequences of late or incomplete forms, and requirements such as fitness-for-duty certification if applicable.

Sep 19, 2026

Upload by Jordan Avery