Family Medical Leave Form - Franklin Northwest Supervisory Union

ADVERTISEMENT

Family Medical Leave Form
Franklin Northwest Supervisory Union
Name:_________________________
Date completing form____________
School_________________________
Position_____________________________________
Reason for requesting leave____________________________________________________________
Date leave begins: ________________________ Anticipated date of return: _____________________
Total number of employment days requested:______________________ Number of paid employment
days (if accrued) requested (not in addition to medical leave time see # 1 ) ____________________
If you are eligible for FMLA Leave, the leave is for up to 60 unpaid employment days if the following
exists:
1. This leave is for your own health condition. Please list the
reason_____________________________________________________
2. This leave if for a spouse, child, or parent. Please list the
reason_____________________________________________________
3. Other ____________________________________________________________
Using accumulated sick time:
1. If you have accumulated sick time or personal time and your FMLA is for maternity or paternity
leave, you may use up to 30 employment days if you wish to be paid for your leave. This time
will run concurrently with your FMLA leave, it is not in addition to your 60 employment days of
the FMLA Leave.
2. If you have accumulated sick time or personal time and your FMLA is for a documented illness or
injury, you may use up to the entire 60 employment days for this purpose.
Before the FMLA leave is approved, you must:
1. Provide sufficient certification to support your FMLA Leave.
2. The form/doctor’s note must be received by the Superintendent’s office within 15 calendar days
from receipt of this notice. If sufficient information is not provided in a timely manner, your
leave may be denied.
3. If you are receiving the health insurance benefits, your health insurance benefits must be
maintained during the period of unpaid FMLA Leave (provided you continue to pay your
employee contribution) for up to 60 employment days (or 12 weeks).

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 3