409.3E2-EMPLOYEE FAMILY AND MEDICAL LEAVE REQUEST FORM

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                               .