Calling 1-877-238-4373 to request a paper form be mailed to you. California Relay Service (711) – Provide the PFL number (1-877-238-4373).This is a sample form for employees to request time off under the Family and Medical Leave Act. Notify your employer about your need for FMLA leave 30 days in advance. The doctor's note must state the date I can return to work. I understand that I may not return to work without providing a doctor's note to Human Resources. How to Request a Family Medical Leave. Purpose. The FMLA is intended "to balance the demands of the workplace with the needs of families. Employees who meet the eligibility criteria for a leave of absence must complete this form at least 30 days prior to the commencement of leave. How to Request a Family Medical Leave. Purpose.