Fillable Application For Family And Medical Leave Form (Page 2 of 2) in pdf

PPLICATION FOR

AMILY AND

EDICAL

EAVE

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

(

)

ISTRICT

PPROVAL

TO BE COMPLETED BY DISTRICT OFFICE ONLY

Leave Designation:

OFLA

FMLA

Both

Provisional Leave Designation (pending

additional information or

medical certification.)

Date employee notified: _______________________ Initials: _____________________________

Short-term conditions requiring only brief treatment and recovery are not “serious health conditions” (e.g., common cold, flu, ear

aches, upset stomach, minor ulcers, headaches other than migraines, routine dental/orthodontia treatments, and routine eye

treatments). Any routine medical, dental, or vision appointment is not considered Sick Child Leave or a Serious Health Condition.

A “Serious Health Condition” means an illness, injury impairment, or physical or mental condition that involves one of the following:

Hospital Care: Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of

incapacity or subsequent treatment in connection with or consequent to such inpatient care.

Absence Plus Treatment: A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or

period of incapacity relating to the same condition), that also involves:

Treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision of a health

care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care

provider; or

Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the

supervision of the health care provider.

i. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition.

Treatment does not include routine physical examinations, eye examinations, or dental examinations.

ii. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or

therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not

include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking

fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.

Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care.

Chronic Conditions Requiring Treatments: A chronic condition is one which:

Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under direct supervision of a

health care provider;

Continues over an extended period of time (including recurring episodes of a single underlying condition); and

May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).

Permanent/Long-Term Conditions Requiring Supervision: A period of incapacity which is permanent or long-term due to a condition

for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be

receiving active treatment by, a health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages of a disease.

Multiple Treatments (Non-Chronic Conditions): Any period of absence to receive multiple treatments (including any period of

recovery there from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care

provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity

of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation,

etc.), severe arthritis (physical therapy), and kidney disease (dialysis).

Serious Injury or Illness of a Covered Service Member: An injury or illness incurred by the service member in the line of duty on

active duty in the Armed Forces that may render the member medically unfit to perform the duties of the member’s office, grade, rank or

rating. A covered service member includes one who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient

status, or is otherwise on the temporary disability retired list, for a serious injury or illness.

Eligibility Rules: Federal Family & Medical Leave Act (FMLA)

Maximum Leave: 12 weeks in a 12-month period (12 consecutive weeks for foster care, adoption, or care for a newborn child in a 12-

month period immediately preceding the birth or placement of the child.)

Eligibility: You must have at least 1 year of employment with Canby School District; and during your last 12 months of

employment prior to the leave request, you must have worked or been paid for at least 1250 hours.

Eligibility Rules: Oregon Family Medical Leave (OFLA)

Maximum Leave: 12 weeks in a 12-month period. Female employees are eligible for an additional 12 weeks in a 12-month period for

pregnancy-related disabilities.

Eligibility: You must have been employed for the 180-day calendar period immediately preceding the leave and in most

cases must also work at least an average of 25 hours per week during the 180-day period.

Canby School District

Rev. 3/2014

Application For Family And Medical Leave Form Page 2

Related Articles

Related forms

Related Categories