Fillable Application For Family And Medical Leave Form printable pdf download

PPLICATION FOR

AMILY AND

EDICAL

EAVE

Oregon Family Medical Leave (OFLA) and/or Federal Family and Medical Leave Act (FMLA)

MPLOYEE

NFORMATION

Employee Group:

Administrator

Licensed

Classified

Confidential/Supervisory Employee #:_________________

Name: _________________________________________

Building Location: ________________________________________

Full-time

Part-time

Regularly scheduled hours per week: _________________

Dates of Anticipated Leave: from _____/_____/_____ through _____/_____/_____

New Application

Revised

EASON FOR

EAVE

For requests due to a serious health condition, including pregnancy, written certification from a health care provider must be provided

to the District using the Certification of Health Care Provider form and submitted to the Personnel Office no later than 30 days prior

to the anticipated leave start date or 15 days after receiving the OFLA/FMLA notification. Select your type of leave below.

Parental Leave. To care for an employee’s newborn, newly adopted or newly placed foster child under 18 years of age

or for a newly adopted or newly placed foster child 18 years of age or older who is incapable of self care because of a

physical or mental impairment. This leave must be taken in one uninterrupted period (no intermittent or reduced work

schedule); however, exceptions may apply to adoption of a child or placement of a foster child.

Care of a newborn child?

Yes

Anticipated birth of child:

____/____/____

Adoption of a child?

Yes

Anticipated date of adoption: ____/____/____

Placement of a foster child?

Yes

Anticipated date of placement: ____/____/____

Employee’s Serious Health Condition (Certification of Health Care Provider required).

Family Member’s Serious Health Condition (Certification of Health Care Provider required). Please select qualifying

family member:

spouse,

child (biological, adopted, foster child, stepchild, legal ward),

child of same gender

domestic partner(OFLA leave only),

grandchild or grandchild (OFLA leave only),

parent,

parent-in-law (OFLA

leave only),

same gender domestic partner (OFLA leave only),

parent of same gender domestic partner.

Name & Address:__________________________________________________________________________________

Pregnancy Disability. Taken by female employee for disability related to pregnancy or childbirth, occurring before or

after the birth of the child, or for prenatal care. (Certification of Health Care Provider required).

Sick Child Leave. To care for an employee’s child suffering from an illness or injury that requires home care but is not a

serious health condition. The child must be under the age of 18 or an adult dependent child substantially limited by a

physical or mental impairment as defined by ORS 659A.100(2)(d). Routine appointments do not qualify.

If your leave is for your child, is anyone else available to care for him/her?

Yes

Military. Please select qualifying for (as define by FMLA regulations):

myself (employee),

spouse

child,

parent,

next of kin

Due to:

Serious Illness or Injury sustained during service,

Exigent Circumstances.

Bereavement. (OFLA leave only) Up to 2 weeks unpaid leave per occurrence, counts towards 12 weeks of OFLA; must

be complete within 60 days of notice.

DDITIONAL

NFORMATION

Will it be necessary for you to take leave only intermittently or to work on a less than regular work schedule as a result of the leave (a

health care provider must authorize a reduced or intermittent work schedule)?

Yes (indicate Reduced or Intermittent)

Reduced schedule starting ___/___/___ Please describe schedule: ___________________________________________

Intermittent leave starting ___/___/___ Please describe schedule: ____________________________________________

I understand that my leave approval may be delayed until the Certification of Health Care Provider form is returned. I understand that in the case of my own serious

health condition, I will not be able to return to work until I provide a release from my health care provider. I understand that the District does require that employees

use appropriate accrued leave before a period of unpaid leave as applicable to my employee group. I agree that while I am on leave, I will continue to pay my share of

insurance premiums, if applicable, unless I elect to discontinue coverage. Finally, I understand that if I do not return to work on the date indicated above (or another

date as specified by me and agreed to by the District), my employment may be terminated by the District as of the date my leave expires.

_______________________________________________

________________________________________________

Employee’s Signature

Date Signed

Canby School District

Rev. 3/2014