I. School District Notice:

1. The district will post the notice in policy 403.7-E9 regarding family and medical leave.
2. Information on the Family and Medical Leave Act (FMLA) and board policy on family and medical leave, including leave provisions and employee obligations, will be available on the district website and through human resources.
3. When an employee requests family and medical leave the district will provide them with information listing the employee’s obligations and requirements. Such information will include:
   
   1. A statement clarifying whether the leave qualifies as family and medical leave and will, therefore, be deducted from the employee’s annual 12-week entitlement, or 26 weeks if military, depending on the purpose of the leave;
   2. A reminder that employees requesting family and medical leave for their own serious health condition or that of an immediate family member, or due to any qualifying exigency, must furnish medical certification of the serious health condition and the consequences for failing to do so or proof of call to active duty in the case of military family and medical leave;
   3. An explanation of the employee’s right to substitute paid leave for family and medical leave including a description of when the district requires substitution of paid leave and the conditions related to the substitution; and
   4. A statement notifying employees that they must pay and must make arrangements for paying any premiums or other payments to maintain health benefits or other benefits.

II. Eligible Employees:  Employees are eligible for family and medical leave if two criteria are met:

1. The employee must have one year of service which need not be continuous provided that a break in service does not exceed seven years. Separate stints of employment will be counted for breaks in service of seven years or longer if one of the following applies:
   
   1. Break in service due to National Guard or reserve military service obligation; or
   2. Written agreement reflecting employer’s intention to rehire the employee after the break in service.
2. The employee has worked 1,250 hours for the district over the previous 12 months. Full-time professional employees who are exempt from the wage and hour law may be presumed to have worked the minimum hour requirement.

If the employee requesting leave is unable to meet the above criteria, they are not eligible for family and medical leave and the district will provide information as to the reason they are not eligible:

1. The employee fails to meet the 12-month service requirement and the number of months the employee has been employed by the district; or
2. The employee fails to meet the 1,250-hour requirement and the number of hours of service worked for the district during the appropriate 12-month period.

III. Employee Requesting Leave - Two Types of Leave:

1. Foreseeable Family and Medical Leave:
   
   1. Definition: leave is foreseeable for the birth or placement of an adopted or foster child with the employee or for planned medical treatment.
   2. The employee must give at least 30-days-notice for foreseeable leave including planned medical treatment for a serious injury or illness of a covered military service member, unless not practicable. Failure to give notice may result in the district counting the absences during the delay as non-FMLA absences.
   3. The employee must consult with the district prior to scheduling planned medical treatment leave to minimize disruption to the district. Scheduling is subject to the approval of the health care provider.
   4. In any case in which the necessity for a qualifying exigency leave is foreseeable, whether because the spouse, son, daughter, or parent of the employee is on active duty in the military, or because of notification of an impending call or order to active duty in support of a contingency operation, the employee shall provide such notice to the district as is reasonable and practicable regardless of how far in advance leave is foreseeable.
       
2. Unforeseeable Family and Medical Leave:
   
   1. Definition: leave is unforeseeable in such situations as emergency medical treatment or premature birth.
   2. The employee must give notice as soon as possible but no later than one-to-two workdays after learning that leave will be necessary.
   3. A spouse or family member may give notice if the employee is unable to personally give notice.

IV: Eligible Family and Medical Leave Determination: The school district may require the employee giving notice of the need for leave to provide reasonable documentation or a statement of family relationship.

1. Six Purposes:
   
   1. The birth of a son or daughter of the employee, and in order to care for that son or daughter prior to the first anniversary of the child’s birth;
   2. The placement of a son or daughter with the employee for adoption or foster care, and in order to care for that son or daughter prior to the first anniversary of the child’s placement;
   3. To care for the spouse, son, daughter, or parent of the employee if the spouse, son, daughter, or parent has a serious health condition; or
   4. The employee’s serious health condition makes the employee unable to perform the essential functions of their position;
   5. Because of any qualifying exigency arising out of the fact that the spouse, son, daughter, or parent of the employee is on active military duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation; and
   6. Because the employee is the spouse, son or daughter, parent, or next of kin of a covered service member with a serious injury or illness. 
       
2. Medical Certification:
   
   1. ​When required:
      • Employees shall be required to present medical certification of their serious health condition and inability to perform the essential functions of their job.
      • Employees shall be required to present medical certification of the family member’s serious health condition and that it is medically necessary for the employee to take leave to care for the family member.
      • Employees shall be required to present certification issued by the health care provider of the military service member being cared for by the employee in the case of an employee unable to return to work because of a condition specified as military service member family leave.
      • Employees shall be required to present certification of next of kin of an individual in the case of leave taken under military service member family leave.
         
   2. Employee’s Medical Certification Responsibilities:
      • The employee must obtain certification from the health care provider who is treating the individual with the serious health condition.
      • The school district may require the employee to obtain a second certification by a health care provider chosen by and paid for by the school district if the district has reason to doubt the validity of the certification an employee submits. The second health care provider cannot, however, be employed by the district on a regular basis.
      • If the second health care provider disagrees with the first health care provider, the school district may require a third health care provider to certify the serious health condition. This health care provider must be mutually agreed upon by the employee and the school district and paid for by the district. The certification, or lack of certification, is binding upon both the employee and the school district.
      • Employees taking military caregiver family and medical leave to care for a family service member cannot be required to obtain a second opinion or to provide recertification.
         
   3. Medical certification must be submitted within 15 days after family and medical leave begins unless it is impracticable to do so. The school district may request recertification every 30 days as follows
      • ​​Upon expiration of period of incapacity specified on certification.
      • If an extension to the leave is requested.
      • If there is significant change in certification (complications, duration/frequency of absences, nature/severity of illness).
      • If the district received information casting doubt upon continuing validity of certification.
         
   4. Family and medical leave requested for the serious health condition of the employee or to care for a family member with a serious health condition which is not supported by medical certification may be denied until such certification is provided.
       
   5. The district may require a request for a qualifying exigency be supported by a military active duty or call to active duty certification issued at such time and in such manner as the regulation prescribes. If a military regulation requiring such certification is issued the employee shall provide, in a timely manner, a copy of the certification to the district.

V. Spouses Employed by the Same Employer: In any case in which a husband and wife entitled to leave are both employed by the district, the aggregate number of work weeks of leave to which both may be entitled may be limited to 12 work weeks during any rolling 12-month period if such leave is taken for:

• Birth of a son or daughter of the employees or in order to care for such son or daughter.
• Because of the placement of a son or daughter with the employees for adoption or foster care, or to care for the child after placement.
• To care for the employee’s parent with a serious health condition or military service member family leave.

The aggregate number of work weeks of leave to which both the husband and wife may be entitled may be limited to 26 work weeks during the single 12-month rolling period if it is military service member family leave or a combination of military service member leave and other leave as described in items 1-3 above. If the leave taken by the husband and wife includes other leave defined in items 1-3 above the limitation of 12 work weeks in a 12-month rolling period applies to that leave.

VI. Entitlement:

1. Employees are entitled to 12 weeks unpaid family and medical leave per year. Employees who are the spouse, son, daughter, parent, or next of kin of a covered military service member who is recovering from a serious illness or injury sustained in the line of duty on active duty shall be entitled to a combined total of 26 work weeks of leave per year to care for the service member and for other types of FMLA leave.
    
2. Year is defined as rolling; measured forward from the first day leave is used.
    
3. If insufficient leave is available, the school district may:
   • Deny the leave if entitlement is exhausted.
   • Award leave available.
   • Award leave in accordance with other provisions of board policy or the collective bargaining agreement.

VII. Type of Leave Requested:

1. Continuous: Employee will not report to work for set number of days or weeks.
    
2. Intermittent: Employee requests family and medical leave for separate periods of time.
   
   1. Intermittent leave is available for:
      
      • Birth, adoption, or foster care placement of child only with the district’s agreement;
      • Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district’s agreement;
      • Any qualifying exigency arising out of the fact that the spouse, son, daughter, or parent of the employee is on active military duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation; or
      • An eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered military service member to care for the military service member who is recovering from a serious illness or injury sustained in the line of duty on active duty.
   2. In the case of foreseeable intermittent leave the employee must schedule the leave to minimize disruption to the school district operation.
   3. During the period foreseeable intermittent leave the district may move the employee to an alternative position with equivalent pay and benefits. (For instructional employees, see VIII below.)
   4. The district may require fit for duty certification every 30 days if the employee has used intermittent leave and reasonable safety concerns exist regarding the employee’s ability to perform his or her duties.
       
3. Reduced Work Schedule: Employee requests a reduction in their regular work schedule.
   
   1. Reduced work schedule family and medical leave is available for:
      
      • Birth, adoption, or foster care placement and subject to the district’s agreement.
      • Serious health condition of the employee, spouse, parent, or child when medically necessary.
      • Any qualifying exigency arising out of the fact that the spouse, son, daughter, or parent of the employee is on active military duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation.
      • An eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered military service member to care for the service member who is recovering from a serious illness or injury sustained in the line of duty on active duty.
   2. In the case of foreseeable reduced work schedule leave based on planned medical treatment for the employee, the employee must schedule the leave to minimize disruption to the school district operation. The district may move the employee to an alternative position with equivalent pay and benefits. (For instructional employees, see VIII below.)
   3. During the period of foreseeable reduced work schedule leave based on planned medical treatment for the family member, the district may move the employee to an alternative position with equivalent pay and benefits. (For instructional employees, see VIII below.)

VIII. Special Rules for Instructional Employees:

1. Definition: An instructional employee is one whose principal function is to teach and instruct students in a class, small group, or individual setting. This includes, but is not limited to, school administrators, teachers, coaches, driver’s education instructors, and special education assistants.
    
2. Instructional employees who request foreseeable, medically necessary intermittent or reduced work schedule family and medical leave greater than 20% of the workdays in the leave period may be required to:
   • Take leave for the entire period, or periods, of the planned medical treatment; or
   • Move to an available alternative position with equivalent pay and benefits but not necessarily equivalent duties for which the employee is qualified.
      
3. Instructional employees who request continuous family and medical leave near the end of a semester may be required to extend the family and medical leave through the end of the semester. The number of weeks remaining before the end of a semester does not include scheduled school breaks such as summer, winter, or spring break.
   • If an instructional employee begins family and medical leave for any purpose more than five weeks before the end of a semester, the district may require that the leave be continued until the end of the semester if the leave will last at least three weeks and the employee would return to work during the last three weeks of the semester if the leave was not continued.
   • If the employee begins family and medical leave for a purpose other than the employee’s own serious health condition during the last five weeks of a semester, the district may require that the leave be continued until the end of the semester if the leave will last more than two weeks, and the employee would return to work during the last two weeks of the semester.
   •    If the employee begins family and medical leave for a purpose other than the employee’s own serious health condition during the last three weeks of the semester and the leave will last more than five working days, the district may require the employee to continue taking leave until the end of the semester.
      
4. The entire period of leave taken under the special rules is credited as family and medical leave. The district will continue to fulfill the school district’s family and medical leave responsibilities and obligations, including the obligation to continue the employee’s health insurance and other benefits if an instructional employee’s family and medical leave entitlement ends before the involuntary leave period expires.

IX. Employee Responsibilities while on Family and Medical Leave:

1. Employee must continue to pay health care benefit contributions or other benefit contributions regularly paid by the employee unless the employee elects not to continue the benefits.
2. The employee contribution payments will be deducted from any money owed to the employee or the employee will reimburse the district at a time set by the superintendent [or designee].
3. An employee who fails to make the health care contribution payments within 30 days after they are due will be notified that their coverage may be canceled if payment is not received within an additional 15 days.
4. An employee may be asked to recertify the medical necessity of family and medical leave for the serious medical condition of an employee or family member once every 30 days or sixth month in the condition of an absence and return the certification within 15 days of the request.
5. The employee must notify the school district of their intent to return to work at least once each month during their leave and at least two days prior to the conclusion of the family and medical leave.
6. If the employee has been absent for more than one calendar week or more, the employee is required to present a fitness-for-duty certificate from their physician stating their ability to perform the essential job functions prior to reporting back to work. If an employee fails to provide a certificate, they will lose their right to reinstatement under the law unless they have requested additional FMLA leave.
7. If an employee intends not to return to work the employee must immediately notify the district in writing of their intent not to return. The district will cease benefits upon receipt of the notification.

X. Use of Paid Leave for Family and Medical Leave: An employee is required to substitute unpaid family and medical leave with any applicable paid leave available to them 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 district determines that paid leave is being taken for an FMLA reason, the district will notify the employee that the paid leave will be counted as FMLA leave.

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Adopted: 1/07
Reviewed: 2/10; 3/11; 12/11; 4/13; 4/20; 4/23
Revised: 2/09; 9/14; 3/17
Related Policy: 403.7; 403.7-R2; 403.7-E1-E9
IASB Reference: 409.03-409.03-E(2); 414.03-414.03-E(2)

Active Duty: The term active duty means duty under a call or order to active duty in support of a contingency operation pursuant to specific enumerated provisions of Section 688 of Title 10 of the United States code. Such active duty or call/order to active duty is only made to members of the National Guard, reserve components, or a retired member of the regular Armed Forces or reserve. Therefore, an employee may not take exigency leave if the servicemember is a member of the regular Armed Forces.

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 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: The term contingency operation has the same meaning given such term in section 101(a)(13) of Title 10, United States 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 full consecutive calendar days and any subsequent treatment or period of incapacity relating to the same condition that also involves:
  
  • In-person treatment by a health care provider at least once within seven days of the first day of incapacity.
  • A regimen of continuing treatment under the supervision of a health care provider.
  • A second in-person visit to the health care provider for treatment (the necessity of which is determined by the health care provider) within 30 days of the first day of incapacity.
  • Any period of incapacity due to pregnancy or for prenatal care. (Father may take FMLA leave for pregnant spouse’s prenatal care and appointments including providing transportation and to provide care after birth if spouse has serious health condition.)
• 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, nurse, or physician’s assistant at least twice a year under direct supervision of a health care provider.
  • Continues over an extended period of time (including recurring episodes of a single underlying condition).
  • 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, 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, 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), and kidney disease (dialysis).

Covered Servicemember: The term covered servicemember means a current member of the Armed Forces, including the National Guard and reserves and those on the temporary disability retired list (TDRL) but not including former members or member on the permanent disability retired list who are undergoing medical treatment, recuperation, therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness. Generally, a former member of the military whose injury or illness manifests itself after the member’s discharge from military service (except for those on the TDRL) is not a covered servicemember.

Eligible Employee: The district has more than 50 employees on the payroll at the time leave is requested. The employee has worked for the school district for one year of service which need not be continuous provided that a break-in-service does not exceed seven years.  Separate stints of employment will be counted for breaks-in-service of seven years or longer if one of the following applies:

1. Break-in-service due to National Guard or reserve military service obligation.
2. Written agreement reflecting an employer’s intention to rehire the employee after the break-in-service.
3. The employee has worked 1,250 hours for the district over the previous 12 months.

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 including parent of a covered servicemember, son or daughter of a covered servicemember, next of kin of a covered servicemember, and son or daughter on active duty or call to active duty status.

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 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.
• 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.
• Physician assistants, 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.
• 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: The individual requires active assistance or supervision to provide daily self-care in several of the activities of daily living (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, 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 non-instructional 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.

Need 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 their own basic medical, hygienic, or nutritional needs or safety or is unable to transport themselves 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. The employee does not need to be the only individual or family member available to provide the care nor is the employee required to provide actual care (e.g., someone else is providing inpatient or home care) as long as the employee is providing at least psychological comfort and reassurance.

Next of Kin: The term next of kin, used with respect to an individual, means the nearest blood relative of that individual.

Outpatient Status: The term outpatient status, with respect to a covered servicemember, means the status of a member of the Armed Forces assigned to:

1. A military medical treatment facility as an outpatient.
2. 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.

Qualifying Exigency: A non-medical activity that is directly related to the covered military member’s active duty or call to active duty status. For an activity to qualify as an exigency it must fall within one of seven categories of activities or be mutually agreed to be the employer and employee. The seven categories of qualifying exigencies are short-notice deployment (leave permitted up to seven days if the military member received seven or less days’ notice of a call to active duty), military events and related activities, certain temporary childcare arrangements and school activities (but not ongoing childcare), financial and legal arrangements, counseling by a non-medical counselor (such as a member of the clergy), rest and recuperation (leave permitted up to five days when the military member is on temporary rest and recuperation leave), and post-deployment military activities.

Reduced Leave Schedule: A leave schedule that reduces the usual number of hours per work week 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 that either prevents the employee from performing the functions of their job or prevents the qualified family member from participating in school or other daily activities.
  • 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 full consecutive calendar days including any subsequent treatment or period of incapacity relating to the same condition that also involves:
      • In-person treatment by a health care provider at least once within seven days of the first day of incapacity.
      • Initiated by the health care provider during the first treatment.
      • A second in-person visit to the health care provider for treatment (the necessity of which is determined by the health care provider) within 30 days of the first day of incapacity.
  • Any period of incapacity due to pregnancy or for prenatal care. (Father may take FMLA leave for pregnant spouse’s prenatal care and appointments including providing transportation and to provide care after birth if spouse has serious health condition).
  • 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, nurse, or physician’s assistant at least twice a year under direct supervision of a health care provider.
    • Continues over an extended period of time (including recurring episodes of a single underlying condition).
    • 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), and 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, flu, earaches, upset stomach, ulcers, headaches other than migraines, 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 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: The term serious injury or illness, in the case of a member of the Armed Forces including a member of the National Guard or reserves, means an injury or illness incurred by the member in 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 physical disability.

Spouse: A husband or wife recognized by Iowa law including common law marriages.

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Adopted: 1/07
Reviewed: 2/10; 3/11; 12/11; 4/13; 3/17; 4/20; 4/23
Revised: 2/09; 9/14
Related Policy: 403.7; 403.7-R1; 403.7-E1-E9
Legal Reference (Code of Iowa): § 20; 216; 279.40; 85; 29 USC §§ 2601; 29 CFR §§ 825
IASB Reference: 409.03-R(2)

Click here to download the FMLA Leave Request Form

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I, [Enter your name], request family and medical leave for the following reasons: (Check all that apply)

​____For the birth of my child. (Employees will be required to use the following leaves if available and applicable: personal illness, family illness, personal days, and paid vacation.)

____For the placement of a child for adoption or foster care. (Employees will be required to use the following leaves if available and applicable: personal days and paid vacation.)

____To care for my child who has a serious health condition. (Employees will be required to use the following leaves if available and applicable: family illness, personal days, and paid vacation.)

____To care for my spouse who has a serious health condition. (Employees will be required to use the following leaves if available and applicable: family illness, personal days, and paid vacation.)

____To care for my parent who has a serious health condition. (Employees will be required to use the following leaves if available and applicable: family illness, personal days, and paid vacation.)

____Because I am seriously ill and unable to perform the essential functions of my position. (Employees will be required to use the following leaves if available and applicable: personal illness, personal days, and paid vacation.)

____Because of any qualifying exigency arising out of the fact that my spouse, son, daughter, or parent is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation. (Employees will be required to use the following leaves if available and applicable: personal days and paid vacation.)

____Because I am the ___spouse; ___son or daughter; ___parent; ___next of kin of a covered service member with a serious injury or illness. (Employees will be required to use the following leaves if available and applicable: family illness, personal days, and paid vacation.)

I understand that when the required paid leave has been used the remainder of the 12 weeks under the Family Medical Leave Act shall be unpaid.

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

I request that my family and medical leave begin on [Enter date], and I request leave as follows: (Check one)
____ Continuous: I anticipate that I will be able to return to work on [Enter date]

____ 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, child, spouse, or parent when medically necessary.

____Because of any qualifying exigency arising out of the fact that my spouse, son, daughter, or parent is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation. (Employees will be required to use the following leaves if available and applicable: family illness, personal days, and paid vacation.)

Details of the needed intermittent leave are: [Be specific with your description]

I anticipate returning to work at my regular schedule on: [Enter date]

____ Reduced work schedule for the:

____Birth of my child or adoption or foster care placement subject to agreement by the district.

____Serious health condition of myself, child, spouse, or parent when medically necessary.

____Because of any qualifying exigency arising out of the fact that my spouse, son, daughter, or parent is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation (employees will be required to use the following leaves if available and applicable: personal days and paid vacation.)

____For the care of my ___spouse; ___son or daughter: ___parent; ___next of kin of a covered service member with a serious injury or illness (Employees will be required to use the following leaves if available and applicable: family illness, personal days, and paid vacation.)

Details of needed reduction in work schedule as follows: [Be specific with your description]

I anticipate returning to work at my regular schedule on: [Enter date]

I realize I may be moved to an alternative position during the period of the family and medical intermittent or reduced work schedule leave. I also realize that with foreseeable intermittent or reduced work schedule leave, subject to the requirements of my health care provider, I may be required to schedule the leave to minimize the impact on school operations.

While on family and medical leave I agree to pay my regular contributions to employer-sponsored benefit plans. My contributions shall be deducted from monies owed me during the leave period. If no monies are owed me, I shall reimburse the school district by personal check (cash) for my contributions. I understand that I may be dropped from employer-sponsored benefit plans for failure to pay my contribution.

I agree to reimburse the district for any payment of my contributions with deductions from future monies owed to me, or the district may seek reimbursement for payments of my contributions in court.

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

I acknowledge that if this request for leave qualifies as family and medical leave it will be deducted from my annual 12-week entitlement.

I acknowledge that the above information is true to the best of my knowledge.

Employee's Printed Name:
Employee's Signature:
Date Signed:

Please return this form to:
Linn-Mar Community School District
Human Resources Office
299 North 10th Street, Marion, IA 52302
Phone: 319-447-3053
Fax: 319-377-9252

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Reviewed: 3/17; 4/20; 4/23
Revised: 9/14; 8/23
Related Policy: 403.7; 403.7-R1-R2; 403.7-E2-E9
IASB Reference: 409.03-E(2); 414.03-E(2)

Click here to download the FMLA Notice of Eligibility, Rights & Responsibilities

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Reviewed: 11/16; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1, E3-E9

Click here to download the FMLA Designation Notice

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Reviewed: 9/14; 11/16; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E2, E4-E9

Click here to download the FMLA Certification of Health Care Provider for EMPLOYEE'S Serious Health Condition form

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Reviewed: 9/14; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E3, E5-E9

Click here to download the FMLA Certification of Health Care Provider for FAMILY MEMBER'S Serious Health Condition form

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Reviewed: 9/14; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E4, E6-E9

Click here to download the Certification of Qualifying Exigency for Military Family Leave form

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Reviewed: 9/14; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E5, E7-E9

Click here to download the Certification for Serious Injury/Illness of a Current Servicemember for Military Family Leave Form

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Reviewed: 9/14; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2, 403.7-E1-E6, E8-E9

Click here to download the Medical Documentation of Absence Form

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It is the practice of the Linn-Mar Community School District to require a fitness-for-duty certificate from their physician if an employee has been absent for one calendar week or more due to the employee's personal injury or illness, prior to reporting back to work.

Please see the attached job description to determine return to full duties or restrictions as necessary.

[Enter employee's name] may return to duties without restrictions on [Enter date].

OR

Due to illness/injury on [Enter date], this employee is not capable of performing the essential functions of their job.

Please indicate any restrictions below and the duration of the restrictions: [Be specific in the details]

Comments:

Anticipated date employee can return to full unrestricted duty: [Enter date]

Physician's Printed Name:
Physician's Signature:
Date Signed:
Business Address:
Business Phone:

Please return this form to:
Linn-Mar Community School District
Human Resources Office
2999 North 10th Street, Marion, IA 52302
Phone: 319-447-3053
Fax: 319-377-9252

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Revised: 9/14; 3/17; 4/20; 4/23; 8/23
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E7; E9

Click here to download the Notice of Employee Rights Under FMLA

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Reviewed: 9/14; 3/17; 4/20
Related Policy: 403.7; 403.7-R1-R2; 403.7-E1-E8