Leave request letter

Date: ____________

To: ____________ (supervisor or human resources)

I am writing to request family or medical leave under the California Family Rights Act.

Reason (check one):

My own serious health condition
To care for my family member, ____________ (relationship), who has a serious health condition
To bond with my new child

Dates: from ____________ to ____________ (or about ______ weeks)

I will provide a health care provider's certification if you need one. Please tell me by ____________ if you need anything else.

Please confirm in writing that my leave is approved and that I will return to my same or a comparable job.

Thank you,

Name: ____________ Signature: ____________

Keep a copy. You do not have to describe the illness in detail. Do not write your immigration status.

From Job Protected Leave. Facts checked October 21, 2026. Free information, not legal or medical advice.

After you print