Norristown Area School District Family & Medical Leave Forms Kit Page 11
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13Family and Medical Leave Request
Page 2
Employee Name _________________________________
4. Yes Have you taken any intermittent family/medical leave?
No
5. Yes Have you taken time off from scheduled hours?
No
If yes, provide details:
6. I request leave for the following reasons:
My own personal serious health condition
Serious health condition of: spouse
child
parent
Birth of a child
Adoption of placement of a child for foster care
Scheduled date of adoption or placement _______________________________
7. Type of Leave Requested:
Consecutive
Intermittent (From time to time as needed, absences must be documented by physician)
8. Dates of Leave Requested:
I request consecutive leave from _________________________________ to _____________________________
I request intermittent leave according to the following schedule:
9. Yes Will you utilize vacation, sick or personal time for pay continuation during your leave?
No
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