Norristown Area School District Family & Medical Leave Forms Kit Page 3
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13NORRISTOWN AREA SCHOOL DISTRICT
Staff Leave Request Instructions
Employee Section
Complete the form indicating reason for leave, requested begin date and anticipated return date and
estimated periods for which you wish to use sick leave, vacation, comp time and/or leave without
pay.
If you are requesting an intermittent leave, you must indicate the intermittent schedule to be worked
(i.e. number of hours per day, begin date and end date of intermittent schedule).
Contact Employee Benefits (610-630-5014) to schedule a meeting to return your completed leave
documents and answer any questions that you may have regarding insurance continuation or your
rights and responsibilities under FMLA.
The Benefits Administrator Section
The Benefits Administrator must complete the Human Resources Section of any applicable forms and submit
completed forms to the appropriate individuals where required.
Indicate if the leave has been approved, provisionally approved (pending medical certification) or if
the leave request has been denied (explanation required).
Refer to Policy and Law below to verify whether the leave is qualified under the law as Family &
Medical Leave (FML). If the leave qualifies as FML provide employee with additional forms. Once
appropriate documentation has been received from the employee and the healthcare provider,
processing of your documents will be completed and your request for leave will be submitted to the
Norristown Area School District School Board for review and approval. If your leave is approved,
you will receive an Employer Response Letter which will indicate the beginning and ending dates of
your leave and any special provisions regarding your requested leave of absence.
Note: FML runs concurrent with paid and unpaid leaves.
Leaves may not extend past a predetermined separation date; for example, the end date of a
limited appointment.
Policy and Law
The federal Family & Medical Leave Act (FMLA) entitles employees to up to 12 weeks of leave for
their own serious health condition; the birth of a child; care of a newborn, newly adopted child or
new foster care placement; or the care of a spouse, child or parent with a serious health condition.
Eligibility Requirements
The employee must have at least 12 months of School District service.
The employee must have worked at least 1250 hours during the 12 months immediately
preceding the commencement of the leave.
The employee must not have utilized their 12 weeks within the current calendar year.
Staff Leave Request
02/11
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