City Of Dallas Family Medical Leave Application Form printable pdf download

City of Dallas

FAMILY MEDICAL LEAVE APPLICATION

INSTRUCTIONS - Part I

1. Employee must fill out all of Part I, Sections A, B & C.

2. Physician must fill out all of Part II – Healthcare Provider Certification. (Necessary except in cases

of Foster Care and Adoption.)

3. Completed Family Medical Leave applications must be submitted to the Human Resource

Generalist 30 days in advance for foreseeable Family Medical Leave.

4. If the leave is not foreseeable, notice must be given to your direct Supervisor or designee as soon

as practical, which ordinarily means at least verbal notification within one (1) to two (2) business

days of when the need for Family Medical Leave becomes known to you, otherwise the time may

be ineligible for designation as Family Medical Leave.

5. In all circumstances, the employee should submit the completed Family Medical Leave application

to their Human Resources Generalist NO LATER THAN FIFTEEN (15) BUSINESS DAYS after

returning to work from a qualifying Family Medical Leave condition/event.

6. Each line on the Family Medical Leave application must be completed even if the response is

N/A (not applicable).

7. Employees of departments without Human Resource Generalists should submit their Family

Medical Leave applications directly to the Client Services Division of Human Resources, 1500

Marilla Street, Room 6AN.

8. Employees requiring intermittent leave must attempt to schedule their leave so as not to disrupt

the employer’s operations.

9. You must call in to your direct supervisor or designee and make them aware that you need to take

Family Medical Leave. If the leave is for someone other than you, state who it is for. (I.e. –

self, child, parent, birth, etc.)

10. Employee must exhaust all accrued sick and vacation leave (respectively) before using unpaid

leave (W-Time), with the exception of adoption or foster care placement where the employee must

first exhaust all accrued paid vacation before using unpaid leave (W-Time).

11. When you return to work, you must indicate on your leave slip or email who you took Family

Medical Leave for. (I.e. – self, child, parent, birth, etc.)

12. When entering your time into Lawson/SEA, make sure you enter the correct code that you

received on your approval letter for Family Medical Leave.

13. Employee must read Administrative Directive 3-72 (Family and Medical Leave), which can be

found on the City’s Intranet or provided to you by Human Resources.

14. Human Resources, with the employees consent, maintains the right to contact your physician

for purposes of clarification and authenticity of the medical certification.

By my signature below, I certify that I have read and understand the above statements and

Administrative Directive 3-72, and have, to the best of my knowledge, provided the accurate

information needed to complete this application.

___________________________________________

__________________________________________

Signature

Date

“Dallas, the City that Works: Diverse, Vibrant and Progressive”

HRD Form Rev.June 2006

City Of Dallas Family Medical Leave Application Form

Related Articles

Related forms

Related Categories