Family And Medical Leave (Fml) Request Form - Arlington Public Schools printable pdf download

FAMILY AND MEDICAL LEAVE (FML) REQUEST FORM

Family Medical Leave Implementation Procedures – PIP 35‐5.6

PLEASE NOTE:

 Family and Medical Leave (FML) is an unpaid leave. You are required to use all accrued Annual, Sick, and Personal

leave, if available, during the FML period.

 It is the employee’s responsibility to notify Human Resources by March 1st of your intent to return to work for

the following school year.

 Employee will be notified as to the status of your leave request after Human Resources has reviewed your request.

Supporting documentation*** must be provided.

 All fields in Sections 1. and 2. must be completed.

Section 1. (please print)

FMLA Start Date:

FMLA Expected Return to Work Date:

Name: (Last, First, Middle Initial)

Employee #:

Position:

Today’s Date:

Your contact information while on leave:

Address: ________________________________________________________________________________________________________

Phone Number: ___________________________________ Email: _______________________________________________________

Your Work Location (Name of School or Department):

Section 2.

Reason for Family and Medical Leave:

□

Your own serious health condition that makes you unable to perform your job

□

Incapacity due to: Pregnancy, Prenatal Medical Care, or Childbirth

□

To care for your child after birth, or placement for adoption or foster care

□

To care for your spouse, son, daughter, or parent who has a serious health condition

□

Military Family Leave

Qualified Exigency

To care for an injured or ill servicemember or veteran

Employee Signature: __________________________________________________________ Date: ____________________

Section 3.

Supervisor Name: ________________________________________________________________________________________________

Please Print

Supervisor Signature: ________________________________________________ Date: __________________________________

Recommendation of Human Resources Department

□

Approved

□

Denied ‐ Reason for Denial: _________________________________________________________________________________

Signature: __________________________________________________________ Date: _________________________________

*** This form must be submitted with the U.S. DOL Certification of Health Care Provider form, thirty days prior to the requested leave

start date or as soon as practical in emergency circumstances. Failure to submit the required documentation will result in an Ineligible

Leave Request. This form can be found on the APS website ( ) or by contacting Human Resources.

APS Family and Medical Leave Request Form (re. December 2017)

Family And Medical Leave (Fml) Request Form - Arlington Public Schools

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