Leave Request | LeaveLogic

1

Select Leave Type

Multiple leave types may apply concurrently

LeaveLogic will automatically check all applicable federal and state leave laws based on the reason selected, and concurrently apply FMLA and state leaves where eligible.

FMLA

Family & Medical Leave Act — federal job protection

ADA / Accommodation

Disability accommodation as leave

State PFML

Paid family & medical leave — state program

Military / USERRA

Military duty — mandatory reinstatement

Parental / Bonding

Birth, adoption, or foster placement

Medical / Disability

STD, LTD, or personal medical leave

Bereavement

Death of family member or loved one

Personal / Other

Company policy personal leave

2

Employee Information

Pre-populated from HRIS if available

First Name *

Last Name *

Employee ID *

Department *

Job Title *

Work State *

Original Hire Date * Used for 12-month FMLA eligibility lookback

Hours Worked (past 12 mo.) * FMLA requires 1,250 hours minimum

Work Location FMLA requires 50+ employees within 75 miles

✓ FMLA Eligible — 12 Weeks Available

✓Employed 12+ months (verified: 3 years, 4 months)

✓1,250+ hours worked in past 12 months (verified: 1,840 hrs)

✓Work site has 50+ employees within 75 miles

✓Qualifying reason (serious health condition)

Available FMLA balance: 480 hours (12 weeks) · State PFML may also apply.

3

Leave Dates & Schedule

Leave Start Date *

Estimated Return Date *

Leave Duration Type *

Schedule During Leave (if reduced hours)

Expected Frequency (intermittent)

4

Leave Reason & Medical Certification

Medical details are encrypted and accessible only to authorized HR personnel. Managers and supervisors do NOT receive diagnosis or treatment information.

General Reason for Leave *

Relationship to Patient (if caring for family member)

Brief Description (internal, not shared with manager) * This description is PHI-protected and audited. Do not use this field to communicate with supervisors.

Medical Certification Required? *

Yes — will upload certification Yes — will provide within 15 days Not applicable (military/bereavement)

Upload Medical Certification

WH-380 (employee), WH-380F (family), military orders, or other supporting documents · PDF, Word, JPEG · Max 25MB

5

Benefits & Pay Continuation

Health Insurance During Leave *

Paid Leave to Substitute? *

STD / Disability Claim Filed?

Yes No Pending

State PFML Claim Filed?

Yes No N/A — state has no PFML

Supervisor / Manager Name *

Leave of Absence Request

✓ FMLA Eligible — 12 Weeks Available