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Include a request for FMLA leave and why you think it qualifies for FMLA protection. Date the leave will begin. Expected date of return to work. Specific dates and times of absence, if applicable.
An employee must have been employed for at least 1,250 hours of service during the 12-month period immediately preceding the commencement of the leave. The hours of service are counted for the 12-month period immediately preceding the leave and generally must be actual hours worked by the employee.
Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave. Please let me know whether you approve this leave at your earliest convenience.
You do not have to tell your employer your diagnosis, but you do need to provide information indicating that your leave is due to an FMLA-protected condition (for example, stating that you have been to the doctor and have been given antibiotics and told to stay home for four days).
When filling out the FMLA forms, be sure to provide accurate and complete information about your need for leave. Include information about your health condition or the health condition of your family member, the expected duration of your absence from work, and any other relevant details.