Code No. 409.3E2

EMPLOYEE FAMILY AND MEDICAL LEAVE REQUEST FORM

Date:                                 

I,                                               , request family and medical leave for the following reason:  

(check all that apply)

        for the birth of my child;

        for the placement of a child for adoption or foster care;

        to care for my child who has a serious health condition;

        to care for my parent who has a serious health condition;

        to care for my spouse who has a serious health condition; or

        because I am seriously ill and unable to perform the essential functions of my position.

___ because of a qualifying exigency arising out of the fact that my ___spouse; ___ son or daughter; ___parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.

___ because I am the ___ spouse; ___ son or daughter; ___ parent; ___next of kin of a covered service member with a serious injury or illness.

I acknowledge my obligation to provide medical certification of my serious health condition or that of a family member in order to be eligible for family and medical leave within 15 days of the request for certification.  

I acknowledge receipt of information regarding my obligations under the family and medical leave policy of the school district.

I request that my family and medical leave begin on                                      and I request leave as follows: (check one)

         continuous

I anticipate that I will be able to return to work on                 .

         intermittent leave for the:

         birth of my child or adoption or foster care placement subject to agreement by the district;

         serious health condition of myself, spouse, parent, or child when medically necessary;

____ because of a qualifying exigency arising out of the fact that my ___ spouse; ___ son or daughter; ___parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.

___ because I am the ___ spouse; ___ son or daughter; ___ parent; ___next of kin of a covered service member with a serious injury or illness.

I anticipate returning to work at my regular schedule on                               .

        4.     An employee may be asked to re-certify the medical necessity of family and medical leave for the serious medical condition of an employee or family member once every thirty days and return the certification within fifteen days of the request.          

        5.     The employee must notify the school district of the employee's intent to return to work at least once each month during their leave and at least two weeks prior to the conclusion of the family and medical leave.

        6.     If an employee intends not to return to work, the employee must immediately notify the school district, in writing, of the employee's intent not to return.  The school district will cease benefits upon receipt of this notification.

I. Use of paid leave for family and medical leave.

An employee may substitute unpaid family and medical leave with appropriate paid leave available to the employee under board policy, individual contracts or the collective bargaining agreement.  Paid leave includes, but is not limited to, sick leave, family illness leave, vacation, personal leave, bereavement leave and professional leave.  When the school district determines that paid leave is being taken for an FMLA reason, the school district will notify the employee within two business days that the paid leave will be counted as FMLA leave.

Adopted: 11/16/2020
Revised:
Reviewed: 06/21/2021

Active Duty - duty under a call or order to active duty under a provision of law referring to in section 101(a)(13) of title 10, U.S. Code.

Common Law Marriage - according to Iowa law, common law marriages exist when there is a present intent by the two parties to be married, continuous cohabitation, and a public declaration that the parties are husband and wife.  There is no time factor that needs to be met in order for there to be a common law marriage.

Contingency Operation - has the same meaning given such term in section 101(a)(13) of title 10, U.S. Code.

Continuing Treatment - a serious health condition involving continuing treatment by a health care provider includes any one or more of the following:

·      A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from) of more than three consecutive calendar days and any subsequent treatment or period of incapacity relating to the same condition that also involves:

        --      treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or in referral by, a health care provider; or

        --      treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of a the health care provider.

·      Any period of incapacity due to pregnancy or for prenatal care.

·      Any period of incapacity or treatment for such incapacity due to a chronic serious health condition.  A chronic serious health condition is one which:

        --      requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care provider;

        --      Continues over an extended period of time (including recurring episodes of a single underlying condition); and

        --      May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).

·      Any period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider.  Examples include Alzheimer's, a severe stroke or the terminal stages of a disease.

·      Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Covered Servicemember - a current member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness. 

Eligible Employee - the district has more than 50 employees on the payroll at the time leave is requested.  The employee has worked for the district for at least twelve months and has worked at least 1250 hours within the previous year.

Essential Functions of the Job - those functions which are fundamental to the performance of the job.  It does not include marginal functions.

Employment Benefits - all benefits provided or made available to employees by an employer, including group life insurance, health insurance, disability insurance, sick leave, annual leave, educational benefits, and pensions, regardless of whether such benefits are provided by a practice or written policy of an employer or through an "employee benefit plan."

Family Member - individuals who meet the definition of son, daughter, spouse or parent.

Group Health Plan - any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer's employees, former employees, or the families of such employees or former employees.

Health Care Provider-

·    A doctor of medicine or osteopathy who is authorized to practice medicine or surgery by the state in which the doctor practices; or

·    Podiatrists, dentists, clinical psychologists, optometrists, and chiropractors (limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X ray to exist) authorized to practice in the state and performing within the scope of their practice as defined under state law; and

·    Nurse practitioners and nurse-midwives, and clinical social workers who are authorized to practice under state law and who are performing within the scope of their practice as defined under state law; and

·    Christian Science practitioners listed with the First Church of Christ Scientist in Boston, Massachusetts;

·    Any health care provider from whom an employer or a group health plan's benefits manager will accept certification of the existence of a serious health condition to substantiate a claim for benefits;

·    A health care provider as defined above who practices in a country other than the United States who is licensed to practice in accordance with the laws and regulations of that country.

In Loco Parentis - individuals who had or have day-to-day responsibilities for the care and financial support of a child not their biological child or who had the responsibility for an employee when the employee was a child.

Incapable of Self-Care - that the individual requires active assistance or supervision to provide daily self-care in several of the "activities of daily living" or "ADLs."  Activities of daily living include adaptive activities such as caring appropriately for one's grooming and hygiene, bathing, dressing, eating, cooking, cleaning, shopping, taking public transportation, paying bills, maintaining a residence, using telephones and directories, using a post office, etc.

Instructional Employee - an employee employed principally in an instructional capacity by an educational agency or school whose principal function is to teach and instruct students in a class, a small group, or an individual setting, and includes athletic coaches, driving instructors, and special education assistants such as signers for the hearing impaired.  The term does not include teacher assistants or aides who do not have as their principal function actual teaching or instructing, nor auxiliary personnel such as counselors, psychologists, curriculum specialists, cafeteria workers, maintenance workers, bus drivers, or other primarily noninstructional employees.

Intermittent Leave - leave taken in separate periods of time due to a single illness or injury, rather than for one continuous period of time, and may include leave or periods from an hour or more to several weeks.

Medically Necessary - certification for medical necessity is the same as certification for serious health condition.

"Needed to Care For" - the medical certification that an employee is "needed to care for" a family member encompasses both physical and psychological care.  For example, where, because of a serious health condition, the family member is unable to care for his or her own basic medical, hygienic or nutritional needs or safety or is unable to transport himself or herself to medical treatment.  It also includes situations where the employee may be needed to fill in for others who are caring for the family member or to make arrangements for changes in care.

Next of Kin - an individual's nearest blood relative

Outpatient Status - the status of a member of the Armed Forces assigned to –

• either a military medical treatment facility as an outpatient; or,
• a unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients.

Parent - a biological parent or an individual who stands in loco parentis to a child or stood in loco parentis to an employee when the employee was a child.  Parent does not include parent-in-law.

Physical or Mental Disability - a physical or mental impairment that substantially limits one or more of the major life activities of an individual.

Reduced Leave Schedule - a leave schedule that reduces the usual number of hours per workweek, or hours per workday, of an employee.

Serious Health Condition -

·       An illness, injury, impairment, or physical or mental condition that involves:

• Inpatient care (i.e. an overnight stay) in a hospital, hospice or residential medical care facility including any period of incapacity (for purposes of this section, defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from), or any subsequent treatment in connection with such inpatient care; or
• Continuing treatment by a health care provider.  A serious health condition involving continuing treatment by a health care provider includes:

--       A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from) of more than three consecutive calendar days, including any subsequent treatment or period of incapacity relating to the same condition, that also involves:

--    Treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders or, or on referral by, a health care provider; or

--    Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.

--       Any period of incapacity due to pregnancy or for prenatal care.

--       Any period of incapacity or treatment for such incapacity due to a chronic serious health condition.  A chronic serious health condition is one which:

--    Requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care provider;

--    Continues over an extended period of time (including recurring episodes of s single underlying condition); and,

--    May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).

--    A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider.  Examples include Alzheimer's a severe stroke or the terminal stages of a disease.

--    Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

·      Treatment for purposes of this definition includes, but is not limited to, examinations to determine if a serious health condition exists and evaluation of the condition.  Treatment does not include routine physical examinations, eye examinations or dental examinations.  Under this definition, a regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition (e.g., oxygen).  A regimen of continuing treatment that includes the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed rest, drinking fluids, exercise and other similar activities that can be initiated without a visit to a health care provider, is not, by itself, sufficient to constitute a regimen of continuing treatment for purposes of FMLA leave.

·      Conditions for which cosmetic treatments are administered (such as most treatments for acne or plastic surgery) are not "serious health conditions" unless inpatient hospital care is required or unless complications develop.  Ordinarily, unless complications arise, the common cold, the flu, ear aches, upset stomach, ulcers, headaches other than migraine, routine dental or orthodontia problems, periodontal disease, etc., are examples of conditions that do not meet the definition of a serious health condition and do not qualify for FMLA leave.  Restorative dental or plastic surgery after an injury or removal of cancerous growths are serious health conditions provided all the other conditions of this regulation are met.  Mental illness resulting from stress or allergies may be serious health conditions, but only if all the conditions of this section are met.

·      Substance abuse may be a serious health condition if the conditions of this section are met.  However, FMLA leave may only be taken for treatment for substance abuse by a health care provider or by a provider of health care on referral by a health care provider.  On the other hand, absence because of the employee's use of the substance, rather than for treatment, does not qualify for FMLA leave.

·      Absence attributable to incapacity under this definition qualify for FMLA leave even though the employee or the immediate family member does not receive treatment from a health care provider during the absence, and even if the absence does not last more than three days.  For example, an employee with asthma may be unable to report for work due to the onset of an asthma attack or because the employee's health care provider has advised the employee to stay home when the pollen count exceeds a certain level.  An employee who is pregnant may be unable to report to work because of severe morning sickness.

Serious Injury or Illness - an injury or illness incurred by a member of the Armed forces, including the National Guard or Reserves in the line of duty on active duty in the Armed Forces that may render the member medically unfit to perform the duties of the member's office, grade, rank, or rating.

Son or daughter - a biological child, adopted child, foster child, stepchild, legal ward, or a child of a person standing in loco parentis.  The child must be under age 18 or, if over 18, incapable of self-care because of a mental or physical disability.

Spouse - a husband or wife recognized by Iowa law including common law marriages.

Adopted:   07/23/2012
Reviewed: 06/21/2021
Revised: 11/16/2020