LICENSED EMPLOYEE FAMILY/MEDICAL LEAVE REQUEST FORM
Date: ________________
I, _________________ , request family and medical leave for the following reason: (check all that apply)
___ for the birth of my child;
___ for the placement of a child for adoption or foster care;
___ to care for my child who has a serious health condition;
___ to care for my parent who has a serious health condition;
___ to care for my spouse who has a serious health condition; or
___ because I am seriously ill and unable to perform the essential functions of my position.
___ because of a qualifying exigency arising out of the fact that my ___spouse; ___ son or daughter; ___ parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.
___ because I am the ___ spouse; ___ son or daughter; ___ parent; ___next of kin of a Covered service member with a serious injury or illness.
I acknowledge my obligation to provide medical certification of my serious health condition or that of a family member in order to be eligible for family and medical leave within 15 days of the request for certification.
I acknowledge receipt of information regarding my obligations under the family and medical leave policy of the school district.
I request that my family and medical leave begin on _________________ and I request leave as follows: (check one)
____ continuous. I anticipate that I will be able to return to work on _____________ .
____ intermittent leave for the:
____ birth of my child or adoption or foster care placement subject to agreement by the district;
____ serious health condition of myself, spouse, parent, or child when medically necessary;
____ because of a qualifying exigency arising out of the fact that my ___ spouse; ___ son or daughter; ___parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.
____ because I am the ___ spouse; ___ son or daughter; ___ parent; ___next of kin of a covered service member with a serious injury or illness.
Details of the needed intermittent leave:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I anticipate returning to work at my regular schedule on _____________________.
____ reduced work schedule for the:
____ birth of my child or adoption or foster care placement subject to agreement by the district;
____ serious health condition of myself, spouse, parent, or child when medically necessary;
____ because of a qualifying exigency arising out of the fact that my ___spouse; ___ son or daughter; ___parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.
____ because I am the ___ spouse; ___ son or daughter; ___ parent; ___next of kin of a covered service member with a serious injury or illness.
Details of needed reduction in work schedule as follows:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I anticipate returning to work at my regular schedule on _______________________ .
I realize I may be moved to an alternative position during the period of the family and medical intermittent or reduced work schedule leave. I also realize that with foreseeable intermittent or reduced work schedule leave, subject to the requirements of my health care provider, I may be required to schedule the leave to minimize interruptions to school district operations.
While on family and medical leave, I agree to pay my regular contributions to employer-sponsored benefit plans. My contributions will be deducted from moneys owed me during the leave period. If no monies are owed me, I will reimburse the school district by personal check or cash for my contributions. I understand that I may be dropped from the employer-sponsored benefit plans for failure to pay my contribution.
I agree to reimburse the school district for any payment of my contributions with deductions from future monies owed to me or the school district may seek reimbursement of payments of my contributions in court.
I acknowledge that the above information is true to the best of my knowledge.
Signed ____________________________________
Date _____________________
If the employee requesting leave is unable to meet the above criteria, the employee is not eligible for family and medical leave.
Approved: 03/15/2021 Reviewed: 02/15/2021 Revised: 02/15/2021
