Suffield Public Schools Family And Medical Leave Of Absence Request Form (Page 3 of 4) in pdf

SUFFIELD PUBLIC SCHOOLS

THIS FORM IS TO BE INCLUDED WITH THE “FAMILY AND MEDICAL LEAVE OF ABSENCE

REQUEST FORM”.

YOUR RIGHTS under the FAMILY AND MEDICAL LEAVE ACT OF 1993 (FMLA)

FMLA requires covered employers to provide up to 15 work weeks of unpaid, job-

protected leave to “eligible” employees for certain family and medical reasons.

Employees are eligible if they have worked for a Suffield Public Schools for at least one

year and for 1,250 hours over the previous 12 months. Suffield Public Schools is exempt

from the Connecticut FMLA per Section 31-51kk of the Connecticut General Statutes,

under #4, “Employer”, which specifically exempts “…the state, a municipality, a local or

regional board of education…”

REASONS FOR TAKING LEAVE: Unpaid leave must be granted for any of the following

reasons:

o To care for the employee’s child after birth, or placement for adoption or foster

care.

o To care for the employee’s spouse, child, or parent, who has a serious health

condition.

o For a serious health condition that makes the employee unable to perform the

employee’s job.

o For 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.

o 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.

At the employee or employer’s option, certain kinds of paid leave may be substituted for

unpaid leave.

ADVANCE NOTICE AND MEDICAL OR MILITARY CERTIFICATION: The employee may be

required to provide advance leave notice and medical or military certification. Taking of

leave may be denied if requirements are not met.

o The employee ordinarily must provide 30 days advance notice when the leave is

“foreseeable.”

o An employer may require medical certification to support a request for leave

because of a serious health condition, and may require second or third opinions (at

the employer’s expense) and a fitness for duty report to return to work.

o Certification is required for an employee’s spouse, child or parent who is a member

of the U.S. Armed Forces called to active duty

Suffield Public Schools Family And Medical Leave Of Absence Request Form Page 3