FMLA Request Forms

When you or a loved one experiences a serious health condition that requires you to take time off from work, the stress from worrying about keeping your job may add to an already difficult situation.

The Family and Medical Leave Act (FMLA) may be able to help. Whether you are unable to work because of your own serious health condition, or because you need to care for your parent, spouse, or child with a serious health condition, the FMLA provides unpaid, job-protected leave. 

Leave may be taken all at once, or may be taken intermittently as the medical condition requires.  A 30-day notice of intent to take FMLA is typical for situations that allow it.

To help you navigate FMLA:

• FMLA GUIDE for employees

• FMLA GUIDE for supervisors

Required Forms

• FMLA Request Form - to be completed by employee

• FMLA Medical Certification - to be completed by health care provider

If you have questions about FMLA, or if you need a form that is not here (FMLA for Military, etc), please contact Katrina Hacker, khacker@ymcacolumbus.org

All forms should also be returned to Katrina Hacker - employees may email, if your doctor requires them to be faxed, please fax to 614-382-​8972.