This is a sample form for employees to request time off under the Family and Medical Leave Act. Request to Return From FMLA Leave: I should fill out the top portion of the form, notifying Human Resources of the date of my return.How Do I Request FMLA Leave? Contact the BSC Benefits Team. Fill out the FMLA request form completely, ensuring all required fields and supporting documents are included. Indicate which of the FMLA-eligible situations applies to you, obtain any additional necessary forms, and fully complete all needed forms. Requesting FMLA has a multi-part, multiple page application, which includes a section for the medical professional to complete and sign.