Family Medical Leave Form - Franklin Northwest Supervisory Union (Page 2 of 3) in pdf

Family Medical Leave Form - Franklin Northwest Supervisory Union Page 2

You will have the following responsibilities while on FMLA Leave:

1. You will need to contact the fiscal services office to make arrangements to continue to pay your

share of the premium payments on your health insurance to maintain health benefits while you

are on leave.

a. If your leave is unpaid, you have a minimum 30-day grace period in which to make

premium employee contribution payments. If payment is not made timely, your group

health insurance may be cancelled, provided we notify you in writing at least 15 days

before the date your health insurance coverage will lapse or at our option, we may pay

your share of the premiums during FMLA leave and recover these payments from you

(withheld from your paycheck) upon your return to work.

b. If you are receiving sick time and/or personal leave time, your employee contributions

to health benefits and other deductions will continue to be withheld from your pay.

2. While on leave, you will be required to furnish periodic reports of your status and intent to

return to work.

3. If the circumstances of your leave changes, and you are able to return to work earlier than the

date requested, you will be required to notify your employer at least two work days prior to the

date you intend to report for work.

Prior to Returning to Work

1. If the circumstances of your leave changes, and you are able to return to work earlier than the

date requested, you will be required to notify your employer at least two work days prior to the

date you intend to report for work.

2. You are required to provide a doctor’s note to verify that you are medically fit to return to work.

Employee’s signature: ___________________________________________ Date:____________

Eligible for FMLA (previously worked for a period of 12 months/on an average of 30 hours per week)

______(yes or no)

Approved:______________________

Not Approved:___________________________

Superintendent’s signature: _______________________________________ Date:____________

Comments: ______________________________________________________________________

Please send this completed form to the Superintendent’s office.

Franklin Northwest Supervisory Union

100 Robin Hood Drive, Suite 2,

Family Medical Leave Form - Franklin Northwest Supervisory Union Page 2