Suffield Public Schools Family And Medical Leave Of Absence Request Form (Page 2 of 4) in pdf

Suffield Public Schools Family And Medical Leave Of Absence Request Form Page 2

I REQUEST TO TAKE MY FAMILY AND MEDICAL LEAVE OF ABSENCE INTERMITTENTLY

DUE TO:

Serious health condition of myself, child, spouse, or parent because of

medical necessity.

Birth, adoption, or foster care

I understand that I must first use all of my accrued personal holiday and vacation time

(and accrued sick leave in the case of employee health condition or a health condition of

child, spouse, or parent if they are living in the same household as the employee) at the

beginning of my family and medical leave of absence as a part of my leave of absence and

before the unpaid portion begins. I understand that failure to return to work on the date

stated above as the leave end date or that misrepresentation of facts on this form will

jeopardize my reinstatement at Suffield Public Schools.

Employee Signature ____________________________________Date: _____________

FOR OFFICE USE ONLY:

The employee has been employed for at least 12 months in the aggregate and

has worked for at least 1,250 actual hours of service during the 12-month

period immediately preceding the date on which the employee’s leave will

commence. (Per 29 CFR 825.500(f) full-time teachers are deemed to have met

the 1250 hour test.)

I have been advised of this employee’s intent to take the indicated family and

medical leave of absence, and, where appropriate such as for leave taken

intermittently, I approve the request.

The employee indicated above has not specifically requested a family and

medical leave of absence, but I am designating the employee’s leave as a leave

that qualifies under the Family and Medical Leave Act.

I am notifying the

employee of my intent by providing him/her a copy of this form.

Response to FMLA Leave request sent to employee within 7 days of receipt of

this form.

Employer Signature: ___________________________ Date: ______________________

Suffield Public Schools Family And Medical Leave Of Absence Request Form Page 2