For agency use only. Additionally, they may take up to 26 weeks of FMLA leave in a single 12-month period to care for a covered service member with a serious injury or illness.To Be Completed By Employee and Attached to Certification Forms. 1 – Click here to open the Leave of Absence (LOA) Request Form. I have a need for leave for a reason that may qualify under the FMLA. •. Once the application and certification forms are submitted to HR, your leave request will be evaluated. The Family and Medical Leave Act (FMLA) is a federal law that provides eligible employees with job-protected leave for qualifying family and medical reasons.