Family And Medical Leave Request Form (Fmla) - Arlington Public Schools
ADVERTISEMENT
1FAMILY AND MEDICAL LEAVE REQUEST (FMLA)
Family Medical Leave Implementation Procedures – PIP 35-5.6
You will be notified as to the status of your leave request after Human Resources has reviewed your request.
Supporting documentation* must be provided.
Please Print – (All fields in Section I and II must be completed)
Section I.
Name: (last, first, middle)
Position:
Date:
Employee#:
Contact information while on Leave:
Address: ________________________________________________________________________________________________________
Phone Number: _______________________________
School or Department: ____________________________________________________________________________________________
Date FMLA leave to begin:
Expected return to work date:
Section II.
Reason for Family and Medical Leave:
□
Your own serious health condition that makes you unable to perform your job
□
Incapacity due to pregnancy, prenatal medical care or childbirth
□
To care for your child after birth, or placement for adoption or foster care
□
To care for your spouse, son, daughter or parent who has a serious health condition
□
Military Family Leave
o
Qualified Exigency
o
To care for an injured or ill servicemember or veteran
Note: It is the employee’s responsibility to notify Human Resources by March 1 of intent to return the following school year.
**Family Medical Leave is unpaid. You are required to use all accrued annual, sick and personal leave, if available during
the FMLA leave period. **
Employee Signature: _________________________________________________
Date: _________________________________
Section III.
Supervisor Name: ________________________________________________________________________________________________
Please Print
Supervisor Signature: ________________________________________________
Date: __________________________________
Recommendation of Human Resources Department
□
Approved
□
Denied Reason for Denial: _________________________________________________________________________________
Signature: ______________________________________
Date: _________________________________
*This form must be submitted along with the Certification of Health Care Provider at least thirty days in advance of the beginning date of
the requested leave or as soon as practical in emergency circumstances, with an explanation as to why the thirty dates was not
practicable. Failure to submit certification will result in disapproval of leave request. This form can be found on the APS website
( ) or by contacting Human Resources.
ACS
Revised January 2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business