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New York City Department of Education

Division of Human Resources

65 Court Street ▪ Brooklyn, New York 11201

Request for Leave under the Family and Medical Leave Act (FMLA)

(For Administrative and Pedagogical Staff)

FMLA leaves may be approved at the local level by the organization head. Applications may be referred to the

Division of Human Resources, Medical, Leaves, and Benefits Office for clarification, where necessary.

Any paid leave for a FMLA qualifying reason, will be counted against annual FMLA leave entitlements.

Employees must provide acceptable certification by a physician or other health care provider for their own serious

health condition or the serious health condition of a covered family member within fifteen (15) calendar days of the

request for leave, where practicable. Leave may be denied if such documentation is not provided. Certification of

fitness to return to work may be required. Employees requesting intermittent leave or leave on a reduced leave

schedule which is medically necessary must advise their responsibility center or school, upon request, of the reasons

the intermittent/reduced leave schedule is necessary and of the schedule for treatment, if applicable. The employee

and the responsibility center or school must attempt to work out a schedule, which meets the employee’s needs

without unduly disrupting the operations of the organization.

Employees requesting child care leave must provide proof that the child is under one (1) year old. Legal

documentation must be attached for employees requesting leave for the placement of a child for adoption or foster

care. Documentation should be provided within fifteen (15) calendar days of the request for leave, where practicable.

The leave may be denied if such documentation is not provided.

Employees are entitled to restoration to the same or an equivalent position upon return from FMLA leave.

Employees’ health coverage will be maintained during approved FMLA leave. Employees must pay the premiums for

any optional riders. Premiums paid by the City during the period of unpaid leave may be recovered if the employee

fails to return to work. Form EB-1054, Health Benefits Report/Inquiry, must be filed by the responsibility center/school

with the Medical, Leaves, and Benefits Office, 65 Court Street, Brooklyn, New York 11201. Documentation indicating

that the leave has been approved must be attached.

Please consult Personnel Memorandum No. 54, 1995-1996 for further information.

SECTION I - TO BE COMPLETED BY THE EMPLOYEE

__________________________________________

_______/_____/________

____________________

Employee’s Name

Social Security Number

EIS #

Civil Service Title or Pedagogical License

Civil Service Status: _____Hourly _____Annual

Pedagogical Status: _____Full-Time _____ Regular Sub.

Work Location:

(

)

Division/Bureau/School

Telephone Number

Work Address:

Street

City

State

Zip Code

Date of commencement of Leave: _____/_____/_____

Probable date of return to work: _____/_____/_____

Date employee goes off payroll _____/_____/_____

I AM REQUESTING LEAVE FOR: (check one)

1. ____Child care due to: (check one)

Birth of child

Placement of child for adoption

Placement of child for foster care

2. ____ Maternity Related Disability

3. ____ Care of seriously ill: (check one)

spouse

parent

child

4. ____ Own serious health condition that makes the employee unable to perform his/her job functions (all paid sick

leave must first be exhausted).

For items 3 & 4:

Check here if intermittent leave is being requested

EMPLOYEE CERTIFICATIONS

CHILD CARE LEAVE CERTIFICATION

, am the parent or legal guardian of (circle one)

Name of Employee

(a). a child born, (b). a child placed for adoption, or (c). a child placed for foster care on ____________________.

Date of Birth or Placement

Note: A copy of the birth certificate; physician’s or other health care provider’s letter; attorney’s letter; letter from an adoption agency or

the appropriate State agency; or other appropriate documentation attesting to the fact and date of birth or placement of the child

must be attached. Child care leave taken under the Family Medical Leave Act must be concluded within 12 months after the

birth, placement for adoption, or placement for foster care of the child.

Employee’s Signature

Date

PLEASE CONTINUE ON REVERSE SIDE

FMLA 2005

Request For Leave Under The Family And Medical Leave Act (Fmla) (For Administrative And Pedagogical Staff) - Nyc Department Of Education

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