FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to "eligible" employees for certain family and medical reasons.   Employees
are eligible if they have worked for a covered employer for at least one year, and for 1,250 hours over the previous 12 months, and if there are at least 50 employees within
75 miles.  The FMLA permits employees to take leave on an intermittent basis or to work a reduced schedule under certain circumstances.\ Leave:                                                          

Unpaid leave must be granted for any of the following reasons:

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

      to care for the employee's spouse, son or 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.

At the employee's or employer's option, certain kinds of paid leave may be substituted for unpaid leave.

The employee may be required to provide advance leave notice and medical certification.  Taking of leave may be denied, if requirements are not met.  The employee
ordinarily must provide 30 days advance notice when the leave is "foreseeable."  An employer may require medical certification to support a request for leave because of
a serious health condition, and may require second or third opinions (at the employer's expense) and fitness for duty report to return to work.

For the duration of FMLA leave, the employer must maintain the employee's health coverage under any "group health plan."  Upon return from FMLA leave, most employees
must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms.

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

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.

The U.S. Department of Labor is authorized to investigate and resolve complaints of violations.

An eligible employee may bring a civil action against an employer for violations.

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.

If you have access to the Internet visit FLMA’s website:  http://www.dol.gov/esa/whd/flma.  Or contact the nearest office of Wage and Hour Division, listed in most
telephone directories under U.S. Government, Department of Labor.  For a listing of records that must be kept by employers to comply with FMLA visit the U.S. Dept. of
Labor’s website: http://www.dol.gov/dol/allcfr/ESA/Title_29/Part_825/29CFR825.500.htm

 

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.

 

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

 

         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 school district

                                           serious health condition of myself, parent, or child when medically necessary

 

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
interruptions to school district operations.

While on family and medical leave, I agree to pay my regular contributions to employer sponsored benefit plans.  My contributions will be deducted from moneys owed me
during the leave period.  If no monies are owed me, I will reimburse the school district by personal check or 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________________

 

1.Employee's Name_____________________________________________________________

 

2.Patient's Name (if different from employee)_________________________________________

 

3.     The attached sheet describes what is meant by a "serious health condition" under the Family and Medical Leave Act.  Does the patient's condition, for which the
employee is taking FMLA leave, qualify under any of the categories described?  If so, please check the applicable category.

            (1)                  (2)                     (3)                     (4)                     (5)                         (6)          

            or                         None of the above

 

4.     Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories:

 

5.     a.   State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient's present incapacity, i.e.
              inability to work, attend school or perform other regular activities due to the serious health condition, treatment therefore, or recovery therefrom, if different):

 

        b.   Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described
in Item 6 below)?

 

              If yes, give the probable duration:

 

        c.   If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated and the likely duration and frequency of episodes
of incapacity:

 

6.     a.   If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments:

If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable
number of and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:

 

        b.     If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the treatments:

 

        c.     If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g. prescription drugs, physical therapy requiring special equipment):

 

7.     a.     If medical leave is required for the employee's absence from work because of the employee's own condition (including absences due to pregnancy or a chronic condition), is the employee unable to perform work of any kind?

 

        b.     If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee's job (the employee or the employer should supply you with information about the essential job functions)?

                If yes, please list the essential functions the employee is unable to perform.

 

        c.     If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment?

 

8.     a.     If leave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation?

 

        b.     If no, would the employee's presence to provide psychological comfort be beneficial to the patient or assist in the patient's recovery?

 

        c.     If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need:

 

 

(Signature of Health Care Provider)_______________________________________________

 

(Type of Practice)____________________________________________________________

 

(Address)___________________________________________________________________

 

(Telephone Number)__________________________________________________________

 

To be completed by the employee needing family leave to care for a family member.

 

State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be
necessary for you to work less than a full schedule:

 

 

 

 

 

 

 

 

_____________________________________________________________ _______________

(Employee Signature)                                                                                                    (Date)

 

A serious health condition means an illness, injury impairment, or physical or mental condition that involves one of the following:

 

1.     Hospital Care - In patient care (i.e. an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent
treatment in connection with or consequent to such inpatient care.

2.     Absence Plus Treatment - A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of incapacity relating
to the same condition), that also involves:

        a.     treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider or by a provider of
health care services (e.g. physical therapist) under the orders of, or on referral by, a health care provider; or

        b.     treatment 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.

3.     Pregnancy - Any period of incapacity due to pregnancy or for prenatal care.

4.     Chronic Conditions Requiring Treatments - A chronic condition which:

        a.     requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under direct supervision of a health care provider;

        b.     continues over an extended period of time (including recurring episodes of a single underlying condition); and

        c.     may cause episodic rather than a period of incapacity (e.g. asthma, diabetes, epilepsy, etc.).

5.     Permanent/Long-term Conditions Requiring Supervision - 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.

6.     Multiple Treatments (Non-chronic Conditions) - Any period of absence to receive multiple treatments (including any period of recovery therefrom) 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).

 

A.      School district notice.

          1.   The school district will post the notice in Exhibit 409.3E1 regarding family and medical leave.

          2.   Information on the Family and Medical Leave Act and the board policy on family and medical leave, including leave provisions and employee obligations will be provided annually.  The information will be in the employee handbook.

          3.   When an employee requests family and medical leave, the school district will provide the employee with information listing the employee's obligations and requirements.  Such information will include:

                a.   a statement clarifying whether the leave qualifies as family and medical leave and will, therefore, be credited to the employee's annual 12-week entitlement;

                b.   a reminder that employees requesting family and medical leave for their serious health condition or for that of an immediate family member must furnish medical certification of the serious health condition and the consequences for failing to do so;

                c.   an explanation of the employee's right to substitute paid leave for family and medical leave including a description of when the school district requires substitution of paid leave and the conditions related to the substitution; and

                d.   a statement notifying employees that they must pay and must make arrangements for paying any premium or other payments to maintain health or other benefits.

 

B.       Eligible employees.

                Employees are eligible for family and medical leave if three criteria are met.

                1.   The school district has more than 50 employees on the payroll at the time leave is requested;

                2.   The employee has worked for the school district for at least twelve months or 52 weeks (the months and weeks need not be consecutive); and

                3.    The employee has worked at least 1,250 hours within the previous year.  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, the employee is not eligible for family and medical leave. 

 

C.     Employee requesting leave -- two types of leave.

        1.     Foreseeable family and medical leave

                a.     Definition - leave is foreseeable for the birth or placement of an adopted or foster child with the employee or for planned medical treatment.

                b.     Employee must give at least thirty days notice for foreseeable leave.  Failure to give the notice may result in the leave beginning thirty days after notice was received.

                c.     Employees must consult with the school district prior to scheduling planned medical treatment leave to minimize disruption to the school district.  The scheduling is subject to the approval of the health care provider.

        2.     Unforeseeable family and medical leave.

                a.     Definition - leave is unforeseeable in such situations as emergency medical treatment or premature birth.

                b.     Employee must give notice as soon as possible but no later than one to two work days after learning that leave will be necessary.

                c.     A spouse or family member may give the notice if the employee is unable to personally give notice.

 

D.    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.     Four purposes.

                a.     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;

                b.       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;

                c.     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

                d.     Employee's serious health condition that makes the employee unable to perform the essential functions of the employee's position.

        2.     Medical certification. 

                When required:

                        (1)    Employees may be required to present medical certification of the employee's serious health condition and inability to perform the essential functions of the job.

                        (2)    Employees may 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.

                a.             Employee's medical certification responsibilities:

                        (1)    The employee must obtain the certification from the health care provider who is treating the individual with the serious health condition.

                        (2)    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 school district has reason to doubt the validity of the certification an employee submits.  The second health care provider cannot, however, be employed by the school district on a regular basis.

                        (3)    If the second health care provider disagrees with the first health care provider, then 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 school district.  This certification or lack of certification is binding upon both the employee and the school district.

                b.     Medical certification will be required fifteen days after family and medical leave begins unless it is impracticable to do so.  The school district may request recertification every thirty days.  Recertification must be submitted within fifteen days of the school district's request.

c.     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 will be denied until such certification is provided.

 

E.     Entitlement.

        1.     Employees are entitled to twelve weeks unpaid family and medical leave per year. 

        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:

                a.     Deny the leave if entitlement is exhausted

                b.     Award leave available

 

F.     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.

                a.     Intermittent leave is available for:

                        (1)    Birth, adoption or foster care placement of child only with the school district's agreement.

                        (2)    Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district's agreement.

                b.     In the case of foreseeable intermittent leave, the employee must schedule the leave to minimize disruption to the school district operation.

                c.     During the period of foreseeable intermittent leave, the school district may move the employee to an alternative position with equivalent pay and benefits

        3.     Reduced work schedule - employee requests a reduction in the employee's regular work schedule.

                a.     Reduced work schedule family and medical leave is available for:

                        (1)    Birth, adoption or foster care placement and subject to the school district's agreement.

                        (2)    Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district's agreement.

                b.     In the case of foreseeable reduced work schedule leave, the employee must schedule the leave to minimize disruption to the school district operation.

                c.     During the period of foreseeable reduced work schedule leave, the school district may move the employee to an alternative position with equivalent pay and benefits

 

G.    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 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 school district at a time set by the superintendent.

        3.     An employee who fails to make the health care contribution payments within thirty 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 re-certify the medical necessity of family and medical leave for the serious medical condition of an employee or family member once every thirty days and return the certification within fifteen days of the request. 

        5.     The employee must notify the school district of the employee's intent to return to work at least once each month during their leave and at least two weeks prior to the conclusion of the family and medical leave.

        6.     If an employee intends not to return to work, the employee must immediately notify the school district, in writing, of the employee's intent not to return.  The school district will cease benefits upon receipt of this notification.

 

H.   Use of paid leave for family and medical leave.

An employee may substitute unpaid family and medical leave with appropriate paid leave available to the employee 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 school district determines that paid leave is being taken for an FMLA reason, the school district will notify the employee within two business days that the paid leave will be counted as FMLA leave.