Click here to download the FMLA Leave Request Form
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
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)