Sample Policy: Paid Family and Medical Leave

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The following is a sample paid family and medical leave policy created by The Paid Leave Project. 

[EMPLOYER] is committed to a culture that helps our employees meet the demands of family and employment responsibilities.  Offering our employees the option of taking paid time off when they or a family member is sick is not just good for our employees and their families, it’s good for our business.

Therefore, it is our policy to provide up to [#] weeks of paid family and medical leave in a 12-month period to eligible employees as defined below.


To be eligible for paid Family and Medical leave (PFML), an employee must:

  1. Have been employed by [EMPLOYER] as a full-time or part-time employee (as defined by [EMPLOYER]) for [#] months before leave is to begin, and
  2. Require leave from work for a reason covered by the Federal Family and Medical Leave Act, as explained below.

Reasons for Leave 

An eligible employee can take PFML for any of the following reasons:

  • For the employee’s own serious health condition;
  • For the birth of the employee’s child, and to care for the newborn child;
  • For the placement of a child with the employee for adoption or foster care; or
  • To care for the employee’s spouse, domestic partner, child, or parent[1] who has a serious health condition.

Use of PFML, Rate of Pay and Benefits While on Leave 

PFML will be subject to the following general requirements:

  1. Generally, employees are entitled to take up to [#] weeks of leave in a single 12-month period for the reasons specified above. For the purposes of this policy, [EMPLOYER] will calculate the amount of PFML available to an employee using a “rolling” 12-month period.  Available leave is determined by subtracting the number of weeks of PFML taken during this 12-month “look back” period from the 12-week total allowed.
  2. Any PFML taken for the birth/adoption/foster care placement of a child must be completed within one year after the date of birth or placement.
  3. Full-time employees will be compensated at the employee’s regular, base weekly rate of pay. Part-time employees’ compensation will be pro-rated based on an average number of hours worked in the [#] months before leave begins.
  4. If the reason for PFML also is covered by the [EMPLOYER’s] short-term benefits policy (or other policies), benefits will run concurrently. However, [EMPLOYER] will supplement the employee’s pay so that the employee receives 100 percent compensation during the period of leave.
  5. To the extent applicable, PFML will run concurrently with federal FMLA and any leave provided under state or local law.
  6. If an employee is enrolled in group health insurance or other insurance benefits, these benefits will continue as if the employee had not taken leave. However, the employee is responsible for his/her portion of the premiums due on the coverage.

How to Request PFML 

If an employee requests leave for a reason that the employee believes qualifies under this policy, the employee must comply with [EMPLOYER’s] absence notification policy [include reference to handbook page here]. Failure to comply with [EMPLOYER’s] absence reporting policies and procedures or to provide documentation or information requested may result in delay or denial of requested time off and/or discipline.


In support of the need for PFML, the employee must provide a complete and sufficient certification form to [EMPLOYER] within 15 calendar days after [EMPLOYER] requests it. If it is not practicable for the employee to provide a certification within 15 days despite the employee’s diligent, good faith efforts to do so, the employee must contact [EMPLOYER CONTACT] within 15 days to explain the situation.


If an employee timely returns from PFML and used the leave for the stated purpose, the employee will be reinstated to the same position held when leave began, or to an equivalent position with equivalent benefits, pay and other terms and conditions of employment.

Before returning to work from PFML for the employee’s own serious health condition, the employee may be required to submit certification from a health care provider that the employee is able to resume work.


The following conduct is strictly prohibited in relation to PFML:

  • Engaging in fraud, misrepresentation or providing false information to [EMPLOYER] or any health care provider.
  • Failure to comply with the employee’s obligations under this policy.
  • Failure to timely return from the leave.

Employees who engage in such conduct will be subject to loss of benefits, denial or termination of PFML, and discipline.

Compliance with State and Local law

[EMPLOYER] recognizes the co-existence of state and/or local laws regarding family and medical leave.  Where such laws apply and provide greater family and medical leave rights than this policy, [EMPLOYER] will comply with those laws.

Please note that the information provided, while research-based, is not guaranteed for accuracy and legality. Please seek legal assistance, or assistance from state or federal governmental resources, to make certain your legal interpretation and decisions are correct. This information is for guidance, ideas, and assistance.