409.3E2 LICENSED 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/daughter, or 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/daughter, parent, or 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 cars placement subject to
agreement by the district
______ serious health condition of myself, parent, or child when
medically necessary
______ because of a qualifying exigency arising out of the fact that my
spouse, son/daughter, or 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/daughter, parent, or 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 school district
______ serious health condition of myself, parent, or child when medically
necessary
______ because of a qualifying exigency arising out of the fact that my spouse,
son/daughter, or parent is on active duty or call to active duty status in
support of a contingency operation as a member of that National Guard or
Reserves.
______ because I am the spouse, son/daughter, parent, or 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 school district operations.
While on family and medical leave, I agree to pay my regular contributions to employer sponsored benefit plans. My contributions shall be deducted from moneys owed me during the leave period. If no monies are owed me, I shall 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.