404.7E2 - 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.

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, or child when medically necessary

                   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

 

                   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 or following 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 moneys 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                                                                  

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