409.3E6 - Family and Medical Leave Request Work Sheet
409.3E6 - Family and Medical Leave Request Work SheetComplete this work sheet upon receiving a request for family and medical leave that may qualify under the Family Medical Leave Act. Be sure to note the requirements relating to family and medical leave in the District's policy/collective bargaining agreement prior to relying on this work sheet as the sole source of the District's obligations. Also be sure to note the definitions in the Regulations.
Section I: Eligible Employee. (Please check all that apply.)
Covered by a policy/collective bargaining agreement. (If checked, please move to Section II.)
The employee must meet all criteria below to move to Section II.
50 or more employees are on the payroll of or under contract to the District.
Worked 52 weeks in the District (consecutive or nonconsecutive) or
Worked 12 months in the District (consecutive or nonconsecutive).
Worked 1250 hours for the District in 12 months prior to the request. Full-time professional employees who are exempt from the wage and hour law may be presumed to have worked the minimum hours required.
Section II: Family and Medical Leave Purpose. (One must be checked to move to Section III.)
Birth and care of newborn prior to first anniversary of child's birth.
Care of adopted child or foster care child prior to first anniversary of placement.
Care for serious health condition of spouse, child, child for which employee is "in loco parentis" and for any of these if they are over eighteen and have a disability which prevents the child from caring for himself or herself.
Requested medical certification for family and medical leave due to a serious health condition of the spouse, parent or child on (date).
Received medical certification within 15 days of the request on (date).
Serious health condition of the employee.
Requested medical certification for family and medical leave due to a serious health condition of the employee on (date).
Received medical certification within 15 days of the request on (date).
Other purposes contained in a policy/collective bargaining agreement.
Section III: Timing of Family and Medical Leave Request.
Date of family and medical leave request (date).
Date family and medical leave to begin (date).
Provide FMLA leave information to employee at time of request (date).
(If one is checked, please move to Section IV.)
Leave request for foreseeable family and medical leave is 30 days prior to date family and medical leave begins.
Leave request for foreseeable family and medical leave is in compliance with policy/collective bargaining agreement.
Leave request for foreseeable family and medical leave was made as soon as practicable, and no later than one business day, prior to date family and medical leave begins.
Leave request for unforeseeable family and medical leave was made in accordance with the policy/collective bargaining agreement timelines.
Section IV: Calculation of Available Family and Medical Leave.
Beginning date for 12-month entitlement period: (Check the method adopted by the District.)
X July 1 (fiscal year)
January 1 (calendar year)
September I (school year)
First day of forward 12-month entitlement period
First day of rolling backward 12-month entitlement period______________________
Collective bargaining agreement year
Other
Total family and medical leave for the 12-month entitlement period 12 weeks
Leave taken to date in the entitlement period -
Leave available for the entitlement period
If sufficient family and medical leave is available and the employee qualifies for family and medical leave, the family and medical leave will be granted in accordance with the policy/collective bargaining agreement.
The employee must be informed that the actual family and medical leave taken will be credited to the employee's 12-week entitlement.
If both spouses are employed by the District, they may only take a combined total of 12 weeks during the entitlement period for the birth, adoption or foster care placement prior to the first anniversary of the child's birth or placement and for the care of a parent with a serious health condition.
If insufficient family and medical leave is available, the District may award only the family and medical leave available or award the family and medical leave in accordance with other provisions of the policy/collective bargaining agreement.
Section V: Types of Family and Medical Leave. (Please check all that apply.)
Continuous leave for purposes listed in Section II.
Intermittent leave for birth, adoption or foster care placement prior to first anniversary of child's birth or placement with District approval in accordance with other provisions of the policy/collective bargaining agreement.
Reduced work schedule leave for birth, adoption or foster care placement prior to first anniversary of child's birth or placement with District approval in accordance with other provisions of the policy/collective bargaining agreement.
Intermittent leave if medically necessary for serious health condition of employee or family member and arranged as much as possible to not disrupt the District's operation.
Reduced work schedule leave if medically necessary for serious health condition of employee or family member and arranged as much as possible to not disrupt the District's operation.
Others contained in a policy/collective bargaining agreement.
(Please specify.)
Section VI: Instructional Employee Intermittent or Reduced Schedule Leave.
A policy/collective bargaining agreement extends this rule to non-instructional employees.
A policy/collective bargaining agreement eliminates this rule for instructional employees.
Instructional employees' intermittent or reduced schedule leave for greater than 20 percent of the work days in the family and medical leave period.
Total number of days during leave period
x .20
20 percent of leave days
Days of leave requested
If the number of days requested exceeds 20 percent of the family and medical leave days, the District may require the instructional employee to take family and medical leave for the entire leave period OR transfer the instructional employee to an alternative position with equivalent pay and benefits. The employee must be informed that the actual family and medical leave taken will be credited to the employee's 12-week entitlement.
Section VII: Instructional Employees Family and Medical Leave Special Rules.
Instructional employee.
A policy/collective bargaining agreement extends one or all of these rules to noninstructional employees.
A policy/collective bargaining agreement eliminates one or all of these rules for instructional employees.
The District can require the employee to remain on family and medical leave until end of the semester if each of the following apply:
Leave begins prior to five weeks before end of semester;
Leave is for three weeks or more; and
Employee will return during last three weeks of semester.
Last work day of the semester
Date of fifth week before end of the semester
Date of third week before end of the semester
Date of requested leave
Length of requested leave
Date of return from leave
The District can require employee to remain on family and medical leave for leave other than an employee's serious health condition until end of semester if each of the following apply:
Leave begins during last five weeks before end of semester;
Leave is greater than two weeks; and
Employee will return during last two weeks of semester.
Last work day of the semester
Date of fifth week before end of the semester
Date of second week before end of the semester
Date of requested leave
Length of requested leave
Date of return from leave
The District can require the employee to remain on family and medical leave for purpose other than an employee's serious health condition until the end of the semester if each of the following apply:
Leave begins during last three weeks before end of the semester; and
Leave is greater than five working days.
Last work day of the semester
Date of third week before end of the semester
Date of requested leave
Length of requested leave
The employee must be informed that the actual family and medical leave taken under these rules will be credited to the employee's 12-week entitlement.
Section VIII: Paid or Unpaid Family and Medical Leave.
Provide employee notice whether the family and medical leave is paid or unpaid leave after completing the work sheet in accordance with the policy/collective bargaining agreement.
Policy/collective bargaining agreement allows or requires substitution of paid leave for family and medical leave.
Family and medical leave is unpaid leave.
Section IX: Employee Progress Report.
Arrangements are made with the employee to report to the District on a regular basis during the family and medical leave (please specify).
Requested medical recertification for family and medical leave due to a serious health condition of the spouse, parent or child on (date).
Received medical recertification within 15 days of the request on (date).
Section X: Employee Benefits During Family and Medical Leave.
The employee's health insurance coverage must be continued during the period of family and medical leave (up to 12 weeks). The District may choose to continue other employee benefits to ensure their restoration along with the health insurance upon the employee's return to work. The employee will pay the employee's share of health insurance and other benefits during the leave period.
Arrangements have been made with the employee to continue the employee's share of health insurance premiums while on family and medical leave:
From monies due to the employee
By the first of each month from the employee
Other (please specify)
Arrangements have been made with the employee to continue the employee's share of the employee's other benefits while on family and medical leave:
From monies due to the employee
By the first of each month from the employee
Other (please specify)
The employee has chosen to discontinue all employee benefits while on family and medical leave.
Employees who fail to provide payment of the employee's share of benefits premium during the period of family and medical leave have 15 days following notice to pay the employee's share.
Employees who fail to pay within 15 days after receiving notice of payment due may have employee benefits discontinued.
The District will deduct unpaid employee portion of benefits from monies due to the employee upon return to work, and the employee has signed a written statement authorizing the deduction.
The District will seek recovery of unpaid employee portion of benefits through small claims court or other appropriate recovery process.
Even if the employee chooses to discontinue employee benefits during the period of family and medical leave, the District should exercise great care before discontinuing employee benefits. The District is required to restore the employee to full benefits when the employee returns to work, including group health insurance, without any qualifying period, physical examination, exclusion of pre-existing conditions and other similar requirements.
The District may discontinue the employee's benefits upon receipt of written notice of the employee's intent not to return to work.
Section XI: Key Employees.
Salaried employees among the highest paid ten percent of a District's employees are considered key employees of the District.
Year-to-date earnings for employee
Total weeks of work and paid leave –
Highest pay for employee =
Provide notice to key employee stating the employee is a key employee and the employee may not be reinstated at end of the family and medical leave period if substantial and grievous economic injury exists.
Compile data to justify substantial and grievous economic injury. Substantial and grievous economic injury does not include minor inconvenience and costs typical to the normal operation of the District.
The key employee is entitled to benefits during the family and medical leave in the same manner as other employees.
Section XII: Employee's Return to Work.
Employee is fully restored to the same or an equivalent position with:
Pay and benefits
Health insurance
Life insurance
_____Other benefits or requirements in a policy/collective bargaining agreement