Application Form For Family Or Medical Leave - Wilson County Board Of Education


Wilson County Board of Education
351 Stumpy Lane
Lebanon, TN 37090
Must be submitted to Human Resources/Benefits Department
30 days prior to commencement of leave when the need is foreseeable. If 30 days notice is
not possible, the employee must provide notice as soon as practicable.
All health benefits will terminate after paid days are used if FMLA is not elected
Employee Name: ___________________________ SSN: _____________EE WCBOE ID#: ____________
Complete Address: ___________________________________________________________________
Phone: ___________________________ Email: ___________________________________________
Work Location: __________________ Position: __________________ Date of Hire: _____________
Full time: Yes__ No__ Part-time: Yes__ No__ (If part-time, this FMLA is for job protection only)
Start Date of Anticipated Leave: __________________________________________________________
Expected Date of Return to Work: _________________________________________________________
Reason for Leave (Explain): _____________________________________________________________
Doctor’s Certification attached? ______Yes ______No
An employee requesting leave for the employee’s serious health condition or the serious health condition of
the employee’s spouse, child or parent must submit a verifying medical certification from a physician within
25 days of the date of the application for leave.
I hereby authorize the Wilson County Board of Education benefits analyst to contact my physician to verify
the reason for my requested family and medical leave. Under HIPAA the medical information requested may
only apply to the reason for the requested FMLA leave.
I understand that a failure to return to work at the end of my leave period may be treated as a resignation
unless an extension has been agreed upon and approved in writing by the Wilson County Board of
Employee Signature: _____________________________________Date: _______________
Principal/Supervisor Approval: ______________________________Date: _______________
Human Resources Approval: ________________________________Date: _______________
Benefits Department Approval: ______________________________ Date: _______________
To be completed by the Benefits Department:
Date Application form received: _______________________________
Date Responded to employee: ________________________________
Date employee response received: _____________________________
Effective March 11, 2010


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