Fmla Leave Request Form - North Colonie Central School District
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1N O R T H C O L O N I E C E N T R A L S C H O O L D I S T R I C T
91 Fiddlers Lane
LATHAM, NY 12110
FMLA LEAVE REQUEST FORM
To be completed by the employee and submitted to the Human Resources Office (please print legibly)
Employee Name _________________________________________________________________________
Position __________________________________ School ________________________________________
Supervisor Name: ________________________________________________________________________
**************************************************************************************************************
I am requesting a leave of absence for:
□
Birth of child and/or to care for a newborn child or for placement of a child
through adoption or foster care.
□
My own serious health condition
□
To care for my □ spouse, □ child, or □ parent who has a serious health condition
□
To care for a covered service member with a serious injury or illness who is my
□ spouse, □ child, □ parent, or □ next of kin.
□
A qualifying exigency arising out of my □ spouse’s, □ child’s, or □ parent’s active
military duty or call to active duty status in support of a contingency operation as
a member of the National Guard or Reserve.
My leave is estimated to begin on ________________________________________________________.
My planned return-to-work date is ________________________________________________________.
A medical or qualifying exigency certification is required for all FMLA requests except for
requests due to the birth, care of a newborn, or placement of a child. You will be sent this form,
along with other required notices, by the Human Resources (HR) Department after the HR Dept
receives this form.
□
□
I
plan
do not plan to continue insurance coverage while on leave. If I plan to continue
coverage, I will contact the Payroll Office to make arrangements for payment of premiums. I
understand that all current payroll deductions [including 403(b)] will automatically resume upon
my return to work.
A doctor’s release is required to return to work if the reason for leave is for your own serious
health condition. Please contact the HR Dept. at least one week before your planned return
date to make arrangements.
_____________________________________________________________________________________
Signature
Date
To be completed by Central Administration and HR:
Approval: _______________________________________________ Date: _____________________
Letter sent to employee ____________________ Copy to Supervisor(s) and Payroll _______________________
OFFICE OF HUMAN RESOURCES
(518) 785-8591
11/1/12
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