Family Medical Leave Act Employee Request For Leave Form - Leander Independent School District
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7LEANDER INDEPENDENT SCHOOL DISTRICT
FAMILY MEDICAL LEAVE ACT
EMPLOYEE REQUEST FOR LEAVE FORM
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Family Medical Leave
Assault Leave
1. Name of Employee (First Name, Middle Initial, Last Name)
2. Employee’s Position
3. Employee’s Date of Hire
4. Reason for requested leave
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a. Birth of a son or daughter of the employee and in order to care for such son or daughter
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b. Placement of a son or daughter with employee for adoption or foster care
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c. Because of employee’s own serious health condition that makes him/her unable to perform job functions
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d. In order to care for a spouse, child or parent with a serious health condition
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e. Because of qualifying exigency arising out of the fact that your
spouse;
son or daughter;
parent is on active
duty or status in support of a contingency operation as a member of the National Guard or Reserves.
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f. Because you are the
spouse;
son or daughter;
parent;
next of kin of a covered service-member with a
serious injury or illness.
5. If “d, e, or f” please check one
6. If “d, e, or f” state name and address of relative
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Spouse
Child
Parent
7. Date on which you wish leave to start.
8. Date of anticipated return to work.
9. Are you requesting leave on a full-time basis or intermittent?
10. If “intermittent,” please provide us with a schedule of when
you anticipate you will be unavailable for work.
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Full – Time
Intermittent
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Employees seeking leave because of reason “4 (c)” or “4 (d)” above, must provide medical certification within 15
days.
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Employees seeking to return to work after a leave because of their own serious illness (reason “4 (c)”) also must
provide a medical certification of ability to perform job duties before they are allowed to resume work.
I hereby agree that while I am on leave, I will continue to pay my share of health insurance premiums, unless I elect to
discontinue such coverage. I also agree that if I fail to return to work at the end of the leave period, I will reimburse the
District for the cost of health benefits provided during my leave, unless I fail to return to work because of continuation,
recurrence, or onset of a serious health condition or because of circumstances beyond my control. If I am unable to return to
work because of a serious health condition, I will provide medical certification from the appropriate health care provider. The
certification will state that I am unable to perform the functions of my position on the date that my leave expired or that I am
needed to care for my spouse/parent/child because he/she has a serious health condition on the date that my leave expired.
Signed
Dated
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