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Minnesota Family and Medical Leave of Absence Request Form

Author: Katherine Hinde, Littler

When to Use

A covered employer in Minnesota 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 Minnesota's Pregnancy and Parenting Leave Act (PPLA).

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 PPLA covers employers that employ one or more employees.

Customizable Form