Illinois Application for Family Medical Leave of Absence

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Multi-State
Control #:
US-425EM
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Word; 
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Description

This form may be used by an employee to request leave under the FMLA.
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FAQ

To apply for FMLA, the employee must take an FMLA Medical Certification Form to their health care provider. This form ensures that the employee's or family member's applicable health condition is valid. After receiving the form, the employee must return it within 15 calendar days.

In order to be eligible to take leave under the FMLA, an employee must (1) work for a covered employer, (2) work 1,250 hours during the 12 months prior to the start of leave, (3) work at a location where 50 or more employees work at that location or within 75 miles of it, and (4) have worked for the employer for 12

You have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family and medical reasons, including up to 12 weeks of unpaid leave in a 12-month period for the birth of a child or placement of a child for adoption or foster care, for a leave related to your own or a family

By Lisa Guerin, J.D. Like employers in every state, Illinois employers must comply with the federal Family and Medical Leave Act (FMLA), which allows eligible employees to take unpaid leave, with the right to reinstatement, for certain reasons.

You have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family and medical reasons, including up to 12 weeks of unpaid leave in a 12-month period for the birth of a child or placement of a child for adoption or foster care, for a leave related to your own or a family

Working Families in Illinois Need Comprehensive Paid Leave But few workers have access to paid family leave through their employers or to employer-provided short-term disability insurance.

Your request for a leave of absenceDuring the first paragraph of your letter, state your request for a leave of absence. This is where you include the start date of your absence and the approximate return date. You can include your reason for a leave of absence with as much detail as you feel comfortable with.

Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles.

Paid leave or unpaid? Normally, FMLA leave is unpaid. This means that you do not receive a salary or other wage during the leave period.

Dear (Supervisor / HR Manager): 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.

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Illinois Application for Family Medical Leave of Absence