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, 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.

Details of the needed intermittent leave:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________                                                                                                                                    

I anticipate returning to work at my regular schedule on 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, 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.

                                                Details of needed reduction in work schedule as follows:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________                                                                                                                                   

I anticipate returning to work at my regular schedule on                                    .

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 school district 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 moneys 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 the employer-sponsored benefit plans for failure to pay my contribution.

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

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

Signed                                                                                   

Date                                    

 

Approved:  May 18, 2015      

Revised/Reviewed: January 24, 2022

 

Your Rights Under the Family and Meidcal Leave Act of 1993

Basic Leave Entitlement        

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:

•  for incapacity due to pregnancy, prenatal medical care or child birth;

•  to care for the employee’s child after birth, or placement for adoption or foster care;

•  to care for the employee’s spouse, son, daughter, or parent, who has a serious health condition; or

•  for a serious health condition that makes the employee unable to perform the employee’s job.

 

Military Family Leave Entitlements  

Eligible employees whose spouse, son, daughter, or parent is on covered active duty or call to covered active duty status may use their 12-week leave entitlement to address certain qualifying exigencies.  Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings.

 

FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service member during a single 12-month period.  A covered service member is (1) 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*; or (2) a veteran who was discharged or released under conditions other than dishonorable at any time during the five-year period prior to the first date the eligible employee takes FMLA leave to care for the covered veteran, and who is undergoing medical treatment, recuperation, or therapy for a serious injury or illness.*

 

*The FMLA definitions of “serious injury or illness” for current service members and veterans are distinct from the FMLA definition of “serious health condition”.

 

Benefits and Protection                     

During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms.

 

Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.

 

Job Eligibility Requirements 

Employees are eligible if they have worked for a covered employer for at least 12 months, for 1,250 hours of service in the previous 12 months*, and if at least 50 employees are employed by the employer within 75 miles.

 

*Special hours of service eligibility requirements apply to airline flight crew employees.

 

Definition of Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities.

 

Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment.

 

Use of Leave  

An employee does not need to use this leave entitlement in one block.  Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis.

Substitution of Paid Leave for Unpaid Leave

Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer’s normal paid leave policies.

 

Employee Responsibilities                                      

Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable.  When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures.

 

Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave.

 

Employer Responsibilities

Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees’ rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility.

 

Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee’s leave entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notify the employee.

 

Unlawful Acts by Employers

FMLA makes it unlawful for any employer to:

•  interfere with, restrain, or deny the exercise of any right provided under FMLA;

•  discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.

 

Enforcement                                                              

An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer.

 

FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights.

 

FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text of this notice.  Regulation 29 C.F.R. § 825.300(a) may require additional disclosures.

 

For additional information:

1-866-4US-WAGE (1-866-487-9243)

TTY: 1-877-889-5627

WWW.WAGEHOUR.DOL.GOV

 

U.S. Department of Labor

Wage and Hour Division

WHD Publication 1420

 

Revised January 24, 2022

 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.

Continuing treatment by a health care provider - one or more of the following:

• The employee or family member in question is treated two or more times for the injury or illness by a health care provider.  Normally this would require visits to the health care provider or to a nurse or physician's assistant under direct supervision of the health care provider.
• The employee or family member is treated for the injury or illness two or more times by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider, or is treated for the injury or illness 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--for example, a course of medication or therapy--to resolve the health condition.
• The employee or family member is under the continuing supervision of, but not necessarily being actively treated by, a health care provider due to a serious long-term or chronic condition or disability which cannot be cured.  Examples include persons with Alzheimer's, persons who have suffered a severe stroke, or persons in the terminal stages of a disease who may not be receiving active medical treatment.

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 or 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 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 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.

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 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 for periods from an hour or more to several weeks.

"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.

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 work week, or hours per workday, of an employee.

Serious health condition-an illness, injury, impairment, or physical or mental condition that involves:

• Any period of incapacity or treatment in connection with or consequent to impatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility;
• Any period of incapacity requiring absence from work, school, or other regular daily activities, of more than three calendar days, that also involves continuing treatment by (or under the supervision of) a health care provider; or
• Continuing treatment by (or under the supervision of) a health care provider for a chronic or long-term health condition that is incurable or so serious that, if not treated, would likely result in a period of incapacity of more than three calendar days; and for prenatal care.
• Voluntary or cosmetic treatments (such as most treatments for orthodontia or acne) which are not medically necessary are not "serious health conditions," unless inpatient hospital care is required.  Restorative dental surgery after an accident, or removal of cancerous growths are serious health conditions provided all the other conditions of this regulation are met.  Treatments for allergies or stress, or for substance abuse, are serious health conditions if all the conditions of the regulation are met.  Prenatal care is included as a serious health condition.  Routine preventive physical examinations are excluded.

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.

 

Approved:  May 18, 2015      

Revised/Reviewed: January 24, 2022