Rhode Island Family and Medical Leave of Absence Request Form

Author: Katherine Hinde, Littler

When to Use

A covered employer in Rhode Island 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 Rhode Island Parental and Family Medical Leave Act (RIPFMLA).

Employer coverage under these laws are as follows:

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

Customizable Form