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 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, ___ parent, ___ spouse, 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, parent, spouse, 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 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     _________________________________________________________________

 

 

Approved:  Oct. 12, 2009, February 18, 2019          
Reviewed:  Sep. 14, 2009, Apr. 5, 2013, Jan.21, 2019      
Revised: