Hawaii Family and Medical Leave of Absence Request Form

Author: Katherine Hinde, Littler

When to Use

A covered employer in Hawaii 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), the Hawaii Family Leave Law (HFLL) and/or Hawaii's pregnancy disability leave law.

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 HFLL covers employers that employ 100 or more employees for each working day during 20 or more calendar weeks in the current or preceding calendar year.
• The pregnancy disability leave law covers all employers in Hawaii.

Customizable Form