District of Columbia Family and Medical Leave of Absence Request Form

Author: Katherine Hinde, Littler

When to Use

A covered employer in the District of Columbia can use this form to receive employee requests for a family and medical leave of absence covered by the federal Family and Medical Leave Act (FMLA) and/or the District of Columbia Family and Medical Leave Act (DC FMLA).

Employer coverage under these laws is as follows:

• The FMLA covers employers that employ 50 or more employees in 20 or more workweeks in the current or preceding calendar year and that are engaged in commerce or in any industry or activity affecting commerce.
• The DC FMLA covers employers that employ 20 or more employees in the District during 20 or more calendar workweeks in either the current or preceding calendar year. 

Customizable Form