Norristown Area School District Family & Medical Leave Forms Kit (Page 10 of 13) in pdf

Norristown Area School District Family & Medical Leave Forms Kit Page 10

Family and Medical Leave Request

Date

To Be Completed by Employee:

Employee Name _________________________________________ Social Security # ____________________

Job Title ______________________________________ Principal or Supervisor __________________________

Eligible employee are entitled under the Family and Medical Leave Act (FMLA) to up to 12 weeks of job protected leave for certain

family and medical reasons. Submit this request form to Human Resources at least 30 days before the leave is to commence, when

possible. When submission of the request 30 days in advance is not possible, submit the request as early as possible. The employer

reserves the right to deny or postpone leave for failure to give appropriate notice when such denial/postponement would be permitted

under federal or state law.

Reasons for Requesting Leave

Leave may be granted for any of the following reasons, when the employee meets or exceeds the *Federal requirements for

FMLA:

For a serious health condition that prevents you form performing the duties of your job;

To care for your child, spouse, or parent who had a serious health condition; or

To care for your child after birth, or for placement after adoption or foster care.

1.  Yes Have you worked for the Norristown Area School District (NASD) for a total of 12 months or more?

 No (If “yes”, continue to question 2. If “no”, stop here. Sign and submit this form to Human

Resources).

2.  Yes During the past 12 months, have you worked at least 1,250 hours (approximately eight months of 40 hours

weeks or one year of 25-hour weeks)? (If “yes”, continue to question 3.

 No If “no”, stop here. Sign and submit this form to Human Resources).

3.  Yes Have you previously taken medical or family leave in the past 12 months?

 No

If yes, provide information below:

Previous Dates of Leave

*Under the Federal Guidelines, an employee is eligible for FMLA if they have worked at least 12 months or 1,250 hours in the

year prior to the request.

Norristown Area School District Family & Medical Leave Forms Kit Page 10