Adams County/ohio Valley Local School District Family Medical Leave Act Request Form (Fmla) printable pdf download

Adams County/Ohio Valley Local School District

Family Medical Leave Act Request Form (FMLA)

Submit this request form to the district Superintendent per Board Policy GBR-R at least 30 days prior to the date when the

leave is to begin, unless the leave is unforeseeable, the employee must give notice as early as is practical. An employee shall

provide at least verbal notice sufficient to make the District aware that the employee needs FMLA-qualifying leave, and the

anticipated timing and during of the leave.

Employee Name __________________________________________________________

Requested beginning date of FML____________________________________________

Anticipated ending date of FML _____________________________________________

Purpose of leave __________________________________________________________

The board may require certification from a health care provider containing specific information required under the law if this

is for medical leave/family care leave. Attach U.S. Department of Labor Form WH-380-E to this request if this is for

employee medical leave. Please use WH 380-F for medical leave to provide care for an immediate family member. These

forms are available from the Superintendent, and/or designee, OVSD Web site.

The District requires eligible employees to use any accrued and unused paid vacations, personal or sick leave concurrently

with unpaid FMLA leave. The Board provides leave to eligible employees consistent with the Family and Medical Leave

Act of 1993 (FMLA). Eligible employees are entitled to up to 12 work weeks (or 26 work weeks to care for a covered service

member) of unpaid family and medical leave in a 12-month period. The Board continues to pay the District’s share of the

employee’s health benefits during the leave. Employees will be responsible for payment of all applicable employee premium

costs while on leave. In addition, the District reinstates the employee to the same or an equivalent position after the

employee’s return from leave.

Check the insurance plan which you are currently enrolled prior to your leave.

Medical-Family _____

Dental-Family _____

Life ______

Medical-Single _____

Dental-Single _____

The Board will continue to pay the employee share of your medical (health) premium, but you must make arrangements to

pay the employee’s share once regular paychecks are no longer being issued.

Have you used FML previously while with this employer?

Yes ______

No ______

If yes, what were the dates of that leave?

Start date ____________ End Date _____________

Employee ____________________________________ Date ____________________________

Signature

The Superintendent, or the designee, will respond to this request using the U.S. Department of Labor Form WH-381. The

original will go to the employee. A copy will be forwarded to the Treasurer’s Office which will later be filed in personnel

file.

To be completed by Superintendent or designee

Date Received ________________ Was form WH-380 Attached?

Yes ________ No ________

If Form WH-380 was not attached, is form required to respond?

Yes ________ No ________

If yes, date Form WH-380 was mailed to employee __________________

Superintendent or designee signature ______________________________ Date _________________

Adams County/ohio Valley Local School District Family Medical Leave Act Request Form (Fmla)

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