Last updated on Feb 20, 2026
US-266EM free printable template
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Have you previously received medical or family leave If yes provide information below Dates of leave From To 4. Family and Medical Leave Request Form Date Employee Name SSN Job Title Supervisor Under the Family and Medical Leave Act eligible employees are entitled to up to twelve weeks of unpaid job-protected leave for certain family and medical reasons. EMPLOYEE STATEMENT I agree to return to work on. If circumstances change I agree to inform my supervisor by submitting a NOTICE OF CHANGES IN...APPROVED MEDICAL OR FAMILY LEAVE form. I understand that my benefits will continue during my leave and that I will arrange to pay my share of applicable premiums. Hrs on days of the week for a total of hours per Schedule commenced on Are there 50 or more employees within 75 miles of the facility where employee works Has the workforce been this large for at least 12 months How will the staff member s duties and responsibilities in your unit be handled during his/her leave of absence Employee has...previously requested family or medical leave on Leave taken from Total Supervisor Date Title Telephone Prior leave requests confirmed time APPROVED DENIED for the following reason s Request approved /denied by. When possible submit this request form to your supervisor at least 30 day before the leave is to commence. When submission 30 days in advance is impossible due to unavoidable circumstances submit the request as early as is possible. When permitted under state or federal law employer may...deny or postpone leave for failure to give appropriate notice. ELIGIBILITY 1. Counting any periods of time that you worked for the company whether they were consecutive or not have you worked for the company for a total of 12 months of more YES NO If yes continue to next question* If no stop here. 2. During the past 12 months have you worked at least 1 250 hours approximately eight months of 40-hour weeks or one year of 25-hour weeks 3. Purpose of Leave 5. Have you taken any intermittent leave...If yes provide details REASONS FOR REQUESTING LEAVE I am requesting leave for the following reason Circle one Personal serious health condition Serious health condition of Spouse Name Child Parent Birth of a child Expected delivery date is Adoption or placement of a child for foster care Child s name Scheduled date of adoption or placement DATES OF LEAVE REQUESTED I request leave from to I request intermittent leave according to the following schedule I request a reduced schedule leave according...to the following schedule The total number of days of leave requested. Signature TO BE COMPLETED BY SUPERVISOR Staff member was hired on He/she started in this department on FULL-TIME PART-TIME Regular hours are week. When possible submit this request form to your supervisor at least 30 day before the leave is to commence. When submission 30 days in advance is impossible due to unavoidable circumstances submit the request as early as is possible. When submission 30 days in advance is impossible...due to unavoidable circumstances submit the request as early as is possible. When permitted under state or federal law employer may deny or postpone leave for failure to give appropriate notice.
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What is US-266EM
US-266EM is a document used for the application for a Certificate of Eligibility for a veteran's educational benefits.
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Who needs US-266EM?
Explore how professionals across industries use pdfFiller.
US-266EM is needed by:
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Veterans seeking educational benefits
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Dependents of veterans applying for benefits
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Educational institutions processing veteran benefits
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Legal representatives assisting veterans
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Government agencies verifying eligibility
Comprehensive Guide to the US-266EM Family and Medical Leave Request Form
What is the US-266EM form?
The US-266EM form is a critical document associated with the Family and Medical Leave Act (FMLA). This form is used by employees to formally request leave from their job for qualifying health and family reasons. Completing the form accurately is essential for ensuring the employee’s rights to job-protected leave.
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The primary purpose of the US-266EM form is to document the request for family and medical leave and ensure compliance with federal regulations.
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Accurate completion of the form is vital. Any errors can lead to denial of leave or unnecessary delays.
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pdfFiller offers streamlined processes for editing and signing the US-266EM form, reducing the risk of mistakes.
Who is eligible for family and medical leave?
Under the FMLA, specific criteria determine eligibility for family and medical leave. Employees must meet certain conditions regarding their employment duration and hours worked.
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Employees must have worked for their employer for at least 12 months before they can take FMLA leave.
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A minimum of 1,250 hours must have been worked during the past year leading up to the leave request.
What information is required on the US-266EM form?
The US-266EM form requires several key pieces of information that need to be completed carefully to avoid delays or rejections.
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Include your full name, job title, and Social Security Number which identifies you within the employment system.
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Specify the starting and ending dates of your requested leave, ensuring that they align with company requirements.
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Indicate the reason for your leave, such as personal or family health issues, adoption, etc.
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If applicable, detail how the leave will be taken intermittently throughout the year.
How do you correctly fill out the US-266EM form?
Completing the US-266EM form accurately requires adherence to several guidelines, ensuring that your request is clear and complete.
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Collect any necessary documents (like medical certificates) that support your leave request before starting the form.
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Take advantage of pdfFiller’s interactive features to easily complete each section of the form.
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Follow a structured approach to fill out each section thoroughly and correctly, double-checking your entries.
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Use the electronic signing feature to submit your completed form securely and quickly.
What are the best practices for submitting your family and medical leave request?
Submitting your US-266EM form requires strategic planning to ensure that your request is processed efficiently and on time.
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Make sure to submit your form well ahead of your desired leave dates to allow for processing time.
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If you are unable to submit on time, contact your HR department immediately to explain your situation.
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Ensure that you adhere to your employer’s policy regarding leave requests to avoid issues.
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Utilize pdfFiller’s tracking features to monitor the status of your submitted form accordingly.
What common mistakes should you avoid when filling out the US-266EM form?
Errors in filling out the US-266EM form can lead to delays or outright denial of leave requests, so it is essential to avoid common pitfalls.
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Failing to give the required notice to your employer can negatively impact your leave request.
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Double-check all entries for accuracy, particularly your personal and employment details.
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Clarify your eligibility before filing to ensure you meet the requirements.
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Always review your form to prevent missing information or typographical errors.
What should you do after submitting the US-266EM form?
After you have submitted the US-266EM form, it's essential to understand the subsequent steps and maintain communication with your employer.
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Engage with your supervisor regarding the status of your leave request and any next steps that may be necessary.
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Leverage pdfFiller to keep track of your form's submission status and address any follow-up actions promptly.
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Be prepared for potential outcomes, whether your leave is approved or denied, and have a plan for further actions.
How to fill out the US-266EM
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1.Open pdfFiller and upload the US-266EM document or select it from the templates.
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2.Start by entering the veteran's full name in the designated field.
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3.Provide the veteran's Social Security Number or VA file number to identify their record.
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4.Fill in the contact information, including address, email, and phone number.
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5.Indicate the service branch and dates of service in the specified sections.
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6.Detail educational information, including the institution's name, course of study, and start date.
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7.Complete all required fields, ensuring accuracy to avoid processing delays.
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8.Review the document for any errors or missing information.
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9.Sign and date the document electronically or print it for manual signing.
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10.Save the completed document and submit it according to your institution's guidelines.
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