This document is available at https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/fmlaen.pdf

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.

409.3R1 EMPLOYEE FAMILY AND MEDICAL LEAVE REGULATION

• School district notice.
  
  • The school district will post the notice in Exhibit 409.3E1 regarding family and medical leave.
  • Information on the Family and Medical Leave Act and the board policy on family and medical leave, including leave provisions and employee obligations will be provided annually. The information will be in the employee handbook.
  • When an employee requests family and medical leave, the school district will provide the employee with information listing the employee's obligations and requirements. Such information will include:
    • a statement clarifying whether the leave qualifies as family and medical leave and will, therefore, be credited to the employee's annual 12-week entitlement or 26 week entitlement depending on the purpose of the leave
    • a reminder that employees requesting family and medical leave for their serious health condition or for that of an immediate family member must furnish medical certification of the serious health condition and the consequences for failing to do so or proof of call to active duty in the case of military family and medical leave
    • an explanation of the employee's right to substitute paid leave for family and medical leave including a description of when the school district requires substitution of paid leave and the conditions related to the substitution; and
    • a statement notifying employees that they must pay and must make arrangements for paying any premium or other payments to maintain health or other benefits.

 

• Eligible employees. (choose one)
  
  • Option I:  Employees are eligible for family and medical leave if criteria are met.
    • The employee has worked for the school district for at least twelve months or 52 weeks (the months and weeks need not be consecutive); and
    • The employee has worked at least 1,250 hours during the 12 months immediately before the date FMLA leave is to begin. Full-Time professional employees who are exempt from the wage and hour law may be presumed to have worked the minimum hour requirement.

If the employee requesting leave is unable to meet the above criteria, then the employee is not eligible for family and medical leave.

• Employee requesting leave -- two types of leave.
  
  • Foreseeable family and medical leave.
    • Definition - leave is foreseeable for the birth or placement of an adopted or foster child with the employee or for planned medical treatment.
    • Employee must give at least thirty days notice for foreseeable leave. Failure to give the notice may result in the leave beginning thirty days after notice was received.  For those taking leave due to military family and medical leave, notice should be given as soon as possible.
    • Employees must consult with the school district prior to scheduling planned medical treatment leave to minimize disruption to the school district. The scheduling is subject to the approval of the health care provider.
  • Unforeseeable family and medical leave.
    • Definition - leave is unforeseeable in such situations as emergency medical treatment or premature birth.
    • Employee must give notice as soon as possible but no later than one to two work days after learning that leave will be necessary.
    • A spouse or family member may give the notice if the employee is unable to personally give notice.

 

• Eligible family and medical leave determination. The school district may require the employee, giving notice of the need for leave, to provide reasonable documentation or a statement of family relationship.
  
  • Six purposes.
    • The birth of a son or daughter of the employee and in order to care for that son or daughter prior to the first anniversary of the child's birth;
    • The placement of a son or daughter with the employee for adoption or foster care and in order to care for that son or daughter prior to the first anniversary of the child's placement;
    • To care for the spouse, son, daughter or parent of the employee if the spouse, son, daughter or parent has a serious health condition; or
    • Employee's serious health condition that makes the employee unable to perform the essential functions of the employee's position.
    • Because of a qualifying exigency arising out of the fact that an employee’s 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 the employee is the spouse, son/daughter, parent, or next of kin of a covered service member with a serious injury or illness
  • Medical certification.
    • When required:
      • Employees shall be required to present medical certification of the employee's serious health condition and inability to perform the essential functions of the job.
      • Employees shall be required to present medical certification of the family member's serious health condition and that it is medically necessary for the employee to take leave to care for the family member.
      • Employees shall be required to present certification of the call to active duty when taking military family and medical leave.
    • Employee's medical certification responsibilities:
      • The employee must obtain the certification from the health care provider who is treating the individual with the serious health condition.
      • The school district may require the employee to obtain a second certification by a health care provider chosen by and paid for by the school district if the school district has reason to doubt the validity of the certification an employee submits. The second health care provider cannot, however, be employed by the school district on a regular basis.
      • If the second health care provider disagrees with the first health care provider, then the school district may require a third health care provider to certify the serious health condition. This health care provider must be mutually agreed upon by the employee and the school district and paid for by the school district. This certification or lack of certification is binding upon both the employee and the school district.
    • Medical certification will be required fifteen days after family and medical leave begins unless it is impracticable to do so. The school district may request recertification every thirty days. Recertification must be submitted within fifteen days of the school district's request.
    • Employees taking military caregiver family and medical leave to care for a family service member cannot be required to obtain a second opinion or to provide recertification.

Family and medical leave requested for the serious health condition of the employee or to care for a family member with a serious health condition which is not supported by medical certification shall be denied until such certification is provided.

• Entitlement.
  
  • Employees are entitled to twelve weeks unpaid family and medical leave per year.  Employees taking military caregiver family and medical leave to care for a family service member are entitled to 26 weeks of unpaid family and medical leave but only in a single 12 month period.
  • Year is defined as: Fiscal (July through June) .
  • If insufficient leave is available, the school district may:
    • Deny the leave if entitlement is exhausted
    • Award leave available

 

• Type of Leave Requested.
  
  • Continuous - employee will not report to work for set number of days or weeks.
  • Intermittent - employee requests family and medical leave for separate periods of time.
    • Intermittent leave is available for;
      • Birth, adoption or foster care placement of child only with the school district's agreement.
      • Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district's agreement.
      • 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
    • In the case of foreseeable intermittent leave, the employee must schedule the leave to minimize disruption to the school district operation.
    • During the-period of foreseeable intermittent leave, the school district may move the employee to an alternative position with equivalent pay and benefits.
  • Reduced work schedule - employee requests a reduction in the employee's regular work schedule.
    • Reduced work schedule family and medical leave is available for
      • Birth, adoption or foster care placement and subject to the school district's agreement.
      • Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district's agreement.
      • 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
    • In the case of foreseeable reduced work schedule leave, the employee must schedule the leave to minimize disruption to the school district operation.
    • During the period of foreseeable reduced work schedule leave, the school district may move the employee to an alternative position with equivalent pay and benefits.

 

• Special Rules for Instructional Employees.
  
  • Definition - an instructional employee is one whose principal function is to teach and instruct students in a class, a small group or an individual setting. This includes, but is not limited to, teachers, coaches, driver's education instructors and special education assistants.
  • Instructional employees who request foreseeable medically necessary intermittent or reduced work schedule family and medical leave greater than twenty percent of the work days in the leave period may be required to:
    • Take leave for the entire period or periods of the planned medical treatment; or
    • Move to an available alternative position, with equivalent pay and benefits, but not necessarily equivalent duties, for which the employee is qualified.
  • Instructional employees who request continuous family and medical leave near the end of a semester may be required to extend the family and medical leave through the end of the semester. The number of weeks remaining before the end of a semester do not include scheduled school breaks, such as summer, winter or spring break.
    • If an instructional employee begins family and medical leave for any purpose more than five weeks before the end of a semester, the school district may require that the leave be continued until the end of the semester if the leave will last at least three weeks and the employee, would return to work during the last three weeks of the semester if the leave was not continued.
    • If the employee begins family and medical leave for a purpose other than the employee's own serious health condition during the last five weeks of a semester, the school district may require that the leave be continued until the end of the semester if the leave will last more than two weeks and the employee would return to work during the last two weeks of the semester.
    • If the employee begins family and medical leave for a purpose other than the employee's own serious health condition during the last three weeks of the semester and the leave will last more than five working days, the school district may require the employee to continue taking leave until the end of the semester.
  • The entire period of leave taken under the special rules is credited as family and medical leave. The school district will continue to fulfill the school district's family and medical leave responsibilities and obligations, including the obligation to continue the employee's health insurance and other benefits, if an instructional employee's family and medical leave entitlement ends before the involuntary leave period expires.

 

• Employee responsibilities while on family and medical leave.
  
  • Employee must continue to pay health care benefit contributions or other benefit contributions regularly paid by the employee unless employee elects not to continue the benefits.
  • The employee contribution payments will be deducted from any money owed to the employee or the employee shall reimburse the school district at a time set by the superintendent.
  • An employee who fails to make the health care contribution payments within thirty days after they are due will be notified that their coverage may be canceled-if payment is not received within an additional 15 days.
  • An employee may be asked to re-certify the medical necessity of family and medical leave for the serious medical condition of an employee or family member once every thirty days and return the certification within fifteen days of the request.
  • The employee must notify the school district of the employee's intent to return to work at least once each month during their leave and at least two weeks prior to the conclusion of the family and medical leave.
  • If an employee intends not to return to work, the employee must immediately notify the school district, in writing, of the employee's intent not to return. The school district will cease benefits upon receipt of this notification.

 

• Use of paid leave for family and medical leave.
  
  • An employee may substitute unpaid family and medical leave for the serious health condition of the employee with paid sick, vacation and personal leave. Upon the expiration of paid leave, the family and medical leave for the serious health condition of the employee shall be unpaid.
  • An employee may substitute unpaid family and medical leave for the serious health condition of an employee's family member with paid sick, vacation and personal leave. Upon the expiration of paid leave, the family and medical leave for the serious health condition of an employee's family member shall be unpaid.
  • An employee may substitute unpaid family and medical leave for the birth of a child of the employee and in order to care for that child prior to the first anniversary of the child's birth with sick, vacation and personal leave. Upon the expiration of paid leave, the family and medical leave for the birth of a child of the employee and in order to care-for that child prior to the first anniversary of the child's birth shall be unpaid.
  • An employee may substitute unpaid family and medical leave for the placement of a child with the employee for adoption or foster care and in order to care for that child prior to the first anniversary of the child's placement or adoption with sick, vacation and personal leave. Upon the expiration of paid leave, the family and medical leave for the placement of a child with the employee for adoption or foster care and in order to care for the child prior to the first anniversary of the child's placement or adoption shall be unpaid.
  • An employee may substitute unpaid family and medical leave when a family service member is called to active duty or on call to active duty with sick, vacation, and personal leave.  Upon expiration of the paid leave, the leave is unpaid.
  • When the school district determines that paid leave is being taken for an FMLA reason, the school district will notify the employee within two business days that the paid leave will be counted as FMLA leave.

409.3R2 EMPLOYEE FAMILY AND MEDICAL LEAVE DEFINITIONS

Active Duty – duty under a call or order to active duty under a provision of law referring to in section 101(a)(13) of title 10, U.S. Code.

Common Law Marriage - according to Iowa law, common law marriages exist when there is a present intent by the two parties to be married, continuous cohabitation, and a public declaration that the parties are husband and wife. There is no time factor that needs to be met in order for there to be a common law marriage.

Contingency Operation – has the same meaning given such term in section 101(a)(13) of title 10, U.S. Code.

Continuing treatment - a serious health condition involving continuing treatment by a health care provider includes any one or more of the following:

• A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from) of more than three consecutive calendar days and any subsequent treatment or period of incapacity relating to the same condition that also involves:
  
  • treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or in referral by, a health care provider; or
  • treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of a health care provider.
• Any period of incapacity due to pregnancy or for prenatal care.
• Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. A chronic serious health condition is one which:
  
  • Requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care provider;
  • Continues over an extended period of time (including recurring episodes of a single underlying condition); and
  • May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc).
• Any period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimer's, a severe stroke or the terminal stages of a disease.

 

• Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.) severe arthritis (physical therapy), kidney disease (dialysis).

Covered Servicemember – a current member of the Armed Forces, including a member of that National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness

Eligible Employee - The employee has worked for the district for at least twelve months and has worked at least 1250 hours within the previous year.

Essential Functions of the Job - those functions which are fundamental to the performance of the job. It does not include marginal functions.

Employment Benefits - all benefits provided or made available to employees by an employer, including group life insurance, health insurance, disability insurance, sick leave, annual leave, educational benefits, and pensions, regardless of whether such benefits are provided by a practice or written policy of an employer or through an "employee benefit plan."

Family Member - individuals who meet the definition of son, daughter, spouse or parent.

Group_Health Plan - any_;plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer's employees, former employees, or the families of such employees or former employees.

Health care provider -

• A doctor of medicine or osteopathy who is authorized to practice medicine or surgery by the state in which the doctor practices; or
• Podiatrists, dentists, clinical psychologists, optometrists, and chiropractors (limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X ray to exist) authorized to practice in the state and performing within the scope of their practice as defined under state law; and
• Nurse practitioners and nurse-midwives who are authorized to practice under state law and who are performing within the scope of their practice as defined under state law; and Christian Science practitioners listed with the First Church of Christ, Scientist in Boston, Massachusetts.
• Any health care provider from whom an employer or a group health plan's benefits manager will accept certification of the existence of a serious health condition to substantiate a claim for benefits;
• A health care provider as defined above who practices in a country other than the United States who is licensed to practice in accordance with the laws and regulations of that country.

In Loco Parentis - individuals who had or have day-to-day responsibilities for the care and financial support of a child not their biological child or who had the responsibility for an employee when the employee was a child.

Incapable of self-care - that the individual requires active assistance or supervision to provide daily self-care in several of the "activities of daily living" or "ADLs." Activities of daily living include adaptive activities such as caring appropriately for one's grooming and hygiene, bathing, dressing, eating, cooking, cleaning, shopping, taking public transportation, paying bills, maintaining a residence, using telephones and directories, using a post office, etc.

Instructional employee - an employee employed principally in an instructional capacity by an educational agency or school whose principal function is to teach and instruct students in a class, a small group, or an individual setting, and includes athletic coaches, driving instructors, and special education assistants such as signers for the hearing impaired. The term does not include teacher assistants or aides who do not have as their principal function actual teaching or instructing, nor auxiliary personnel such as counselors, psychologists, curriculum specialists, cafeteria workers, maintenance workers, bus drivers, or other primarily noninstructional employees.

Intermittent Leave - leave taken in separate periods of time due to a single illness or injury, rather than for one continuous period of time, and may include leave or periods from an hour or more to several weeks.

Medically Necessary - certification for medical necessity is the same as certification for serious health condition.

"Needed to Care For" - the medical certification that an employee is "needed to care for" a family member encompasses both physical and psychological care. For example, where, because of a serious health condition, the family member is unable to care for his or her own basic medical, hygienic or nutritional needs or safety or is unable to transport himself or herself to medical treatment. It also includes situations where the employee may be needed to fill in for others who are caring for the family member or to make arrangements for changes in care.

Next of Kin – an individual’s nearest blood relative

Outpatient Status – the status of a member of the Armed Forces assigned to

• Either a military medical treatment facility as an outpatiens; or
• A unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients.

Parent - a biological parent or an individual who stands in loco parentis to a child or stood in loco parentis to an employee when the employee was a child. Parent does not include parent-in-law.

Physical or Mental Disability - a physical or mental impairment that substantially limits one or more of the major life activities of an individual.

Reduced Leave Schedule - a leave schedule that reduces the usual number of hours per workweek, or hours per workday, of an employee.

Serious Health Condition-

• an illness, injury, impairment, or physical or mental condition that involves:
  
  • Inpatient care (i.e. an overnight stay) in a hospital, hospice or residential medical care facility including any period of incapacity (for purposes of this section, defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for a recovery from), or any subsequent treatment in connection with such inpatient care; or
  • Continuing treatment by a health care provider. A serious health condition involving continuing treatment by a health care provider includes:
    • A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for a recovery from) of more than three consecutive calendar days, including any subsequent treatment or period of incapacity relating to the same condition, that also involves:
      • Treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders or, or on referral by, a health care provider; or
      • Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.
  • Any period of incapacity due to pregnancy or for prenatal care
  • Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. A chronic serious health condition is one which:
    • Requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care provider;
      • Continues over an extended period of time (including recurring episodes of a single underlying condition); and
        
        • May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
  • A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimer's, a severe stroke or the terminal stages of a disease.
  • Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

 

• Treatment for purposes of this definition includes, but is not limited to, examinations to determine if a serious health condition exists and evaluation of the condition. Treatment does not include routine physical examinations, eye examinations or dental examinations. Under this definition, a regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition (e.g., oxygen). A regimen of continuing treatment that includes the taking of over-the-counter medications such as aspirin, antihistimines, or salves; or bed rest, drinking fluids, exercise and other similar activities that can be initiated without a visit to a health care provider, is not, by itself, sufficient to constitute a regimen of continuing treatment for purposes of FMLA leave.
• Conditions for which cosmetic treatments are administered (such as most treatments for acne or plastic surgery) are not "serious health conditions" unless inpatient hospital care is required or unless complications develop. Ordinarily, unless complications arise, the common cold, the flu, earaches, upset stomach, ulcers, headaches other than migraine, routine dental or orthodontia problems, periodontal disease, etc., are examples of conditions that do not meet the definition of a serious health condition and do not qualify for FMLA leave. Restorative dental or plastic surgery after an injury or removal of cancerous growths are serious health conditions provided all the other conditions of this regulation are met. Mental illness resulting from stress or allergies may be serious health conditions, but only if all the conditions of this section are met.
• Substance abuse may be a serious health condition if the conditions of this section are met. However, FMLA leave may only be taken for treatment for substance abuse by a health care provider or by a provider of health care on referral by a health care provider. On the other hand, absence because of the employee's use of the substance, rather than for treatment, does not qualify for FMLA leave.
• Absence attributable to incapacity under this definition qualify for FMLA leave even though the employee or the immediate family member does not receive treatment from a health care provider during the absence, and even if the absence does not last more than three days. For example, an employee with asthma may be unable to report for work due to the onset of an asthma attack or because the employee's health care provider has advised the employee to stay home when the pollen count exceeds a certain level. An employee who is pregnant may be unable to report to work because of severe morning sickness.

 

Serious Injury or Illness – an injury or illness incurred by a member of the Armed Forces, including the national Guard or Reserves in the line of duty of active duty

Son or daughter-a biological child, adopted child, foster child, stepchild, legal ward, or a child of a person standing in loco parentis. The child must be under age 18 or, if over 18, incapable of self-care because of a mental or physical disability.

Spouse-a husband or wife recognized by Iowa law including common law marriages.