SUFFIELD PUBLIC SCHOOLS
FAMILY AND MEDICAL LEAVE OF ABSENCE REQUEST FORM
I request to be placed on family and medical leave of absence based on the attached
certification from a health-care provider or the attached documentation related to
adoption or foster care placement.
School / Department:
Request Leave Start Date:
Requested Leave End Date:
REASON FOR LEAVE OF ABSENCE:
FAMILY-RELATED REASONS: (Maximum time allowed is 15 work weeks or 26 weeks
depending on the family-related reasons)
Birth of child or to care for the baby. (Attach copy of the birth certificate or
certification from a health-care provider.)
Adoption of a child by the employee.
(Attach a copy of the adoption papers.)
Placement of a child with the employee for foster care.
(Attach a copy of the foster care placement papers.)
Care of a child, spouse, or parent (but not in-laws) having a serious health
(Attach a copy of certification from a health-care provider.
Children 18 years or older are not included unless they are incapable of self
care due to mental or physical disabilities.)
Care of any “qualifying exigency” (as will be defined by the Department of
Labor) for the employee’s spouse, child or parent who is a member of the U.S.
Armed Forces and is called up to active duty.
To permit a spouse, son, daughter, parent or next of kin to take up to the 26
work weeks of leave to care for a member of the armed forces who is
undergoing medical treatment, recuperation,, or therapy, in otherwise in
outpatient status, or is otherwise on the temporary disability retired list, for
serious injury or illness.
EMPLOYEE HEALTH CONDITION: (Maximum time allowed is 15 work weeks)
Medical leave of absence for a serious health condition that makes me unable
to work. (Attach a copy of certification from a health-care provider.)
Intermittent medical leave for the employee’s own health condition is limited
to a maximum of 15 work weeks.