EMPLOYEE FAMILY AND 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 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 healthcare 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 monies 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.
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Approved: 6/9/25 |
Reviewed: |
Revised: |