Norristown Area School District Family & Medical Leave Forms Kit (Page 12 of 13) in pdf

Norristown Area School District Family & Medical Leave Forms Kit Page 12

Family Medical Leave Request

Page 3

Employee Name _____________________________

10. Please indicate which form and amount of pay continuation that you want to utilize.

 Vacation

__________________

 Sick Time

__________________

 Personal Time

__________________

 40 Day Differential __________________

Please Review Below Carefully:

Employee Statement

I agree that if circumstances change such that I will be unable to return to work on the return date that I have stated, I will inform

Human Resources and my supervisor by submitting written notice. I will provide medical certification from the appropriate

health care provider stating that I am unable to perform the functions of my position on the date that my leave expired or that I am

needed to care for a covered relation because he/she has a serious health condition on the date they my leave expired.

I understand that employees seeking to return to work after a leave because of their own serious illness must complete a Release

to Work Form before they are allowed to resume work. I understand that I may not be permitted to resume my position with the

Norristown Area School District until I provide a completed Release to Return to Work from to the Benefits Administrator.

I understand my benefits will continue during the 12 weeks of FMLA approved leave and I must arrange to pay my share of

applicable premiums. If an employee elects to utilize continuation pay, then they will be actively enrolled in the district benefits

for the length of the continuation pay or the length of their FMLA, whichever is longer. If I do not return to my employment

following the requested period of leave, I understand that I may be required to repay the Norristown Area School District (NASD)

any medical insurance amounts that were paid on my behalf. I also understand that if I terminate my employment with the NASD

at the end of my requested leave period, my medical insurance coverage will convert to COBRA at the end of the month

following my notice of termination or the end of the month of my leave period.

Signature _________________________________________________ Date __________________________________

Submit this completed original form to the attention of Suzanne Basile, Human Resources Department.

Keep a copy for your records.

Norristown Area School District Family & Medical Leave Forms Kit Page 12