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

Wilson County Board of Education

351 Stumpy Lane

Lebanon, TN 37090

APPLICATION FOR FAMILY OR MEDICAL LEAVE

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

NOTE:

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

Education.

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

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