Accommodation & Leave Requests

Request Intermittent FMLA Leave

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Recipient Name

Condition Description

Intermittent Need

Your Name

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Dear [Recipient Name],

I am writing to request intermittent FMLA leave for my serious health condition. Under 29 C.F.R. § 825.202, employees are entitled to take FMLA leave intermittently when medically necessary for a serious health condition.

My condition [Condition Description] requires [Intermittent Need]. My treating provider will certify the medical necessity for intermittent leave on the WH-380-E form.

Please provide me with the appropriate FMLA forms. I will work with my supervisor to minimize disruption while ensuring I receive necessary medical care.

Sincerely,
[Your Name]

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