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Family and Medical Leave Forms

Fill In Forms

These forms can be filled out on your computer (if you have Microsoft Word). After filling out the form you must then print it, sign it and mail it to the Division at the address given on each form.

• Family and Medical Complaint - ERD-8994-E
• Medical Release Authorization - ERD-4972-E
• Request to Withdraw Complaint - 4971-E

Regular Forms

Family and Medical Leave Complaint - This form is provided in English or Spanish.
F&ML Complaint - English | Queja de Ausencia Familiar y Médica - Spanish

Family And Medical Leave Request

Medical Release Authorization

Physician or Practitioner Certification for Family or Medical Leave