Policy Details

4118.15 and 4218.15 FORM Family and Medical Leave

4118.15 / 4218.15

FORM

PERSONNEL

REQUEST FOR LEAVE UNDER

THE FAMILY AND MEDICAL LEAVE ACT OF 1993

Employee Requesting FMLA Leave_________________________________________________________

School____________________________________________________________________________________________

Please be advised that as of _______________________________________________, I give you notice of my need to

(current date)

take Family/ Medical Leave due to:

_____ care for the employee's child after birth or placement for adoption or foster care (must conclude within 12 months of the birth or placement);

_____ care for the employee's _____ spouse, _____ child or _____ parent who has a serious health condition;

_____ a serious health condition that makes the employee unable to perform the functions of his or her position, including incapacity due to pregnancy, prenatal medical care or child birth; or

_____ a qualifying exigency arising out of a family member's military service, including one or more of the following reasons (note – more detailed information on the following categories is available from the Superintendent's office or the office of the
Business office):

(a) short notice deployment;

(b) military events and related activities;

(c) childcare and school activities;

(d) financial and legal arrangements;

(e) counseling;

(f) rest and recuperation;

(g) post-deployment activities;

(h) additional activities that arise out of the active duty or call to active duty status of a covered military member, provided that Litchfield Board of Education and the employee agree that such leave qualifies as an exigency, and agree to both the timing and the duration of such leave.

I need this leave beginning _________________________________, and I expect the leave to continue until on or about
(date)

___________________________________.
(date)

Signature_____________________________________________________ Date______________________________


Litchfield Board of Education
Regulation Adopted: December 10, 1996
Regulation Reviewed: October 1, 1998
Regulation Reviewed: June 10, 2009
Regulation Reviewed: August 10, 2011

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