ATT.
1
FAMILY MEDICAL LEAVE ACT
REQUEST
Employee’s Name
Date
Job Title
District
-------------------------------------------------------------------------------------------------------------
REASON FOR LEAVE:
LEAVE
REQUESTED:
From: Date
To:
Date
Total Number of Days
Requested:
Indicate Regular Work
Hours:
Physician’s
Certification:
Attached
Applicable
Not Applicable
Employee Signature:
Date:
-------------------------------------------------------------------------------------------------------------
PLEASE CIRCLE AND
SIGN:
This leave has been
approved:
Yes
No
Supervisor’s
Signature
-------------------------------------------------------------------------------------------------------------
I recommend this approved
leave: ( ) With Pay
# Days
Available
( ) Without Pay
Authorized Signature
ATT.
2
ELECTION OF EXTENDED
INSURANCE COVERAGE UNDER
FAMILY MEDICAL LEAVE
ACT
1. I acknowledge that during the 12
weeks of FMLA leave, insurance provided directly through the District may be
retained. The District will
continue to pay the same amount toward the premiums as it does when I am in
active status through the end of the month in which the FMLA leave
concludes. At such time as I no
longer receive a paycheck that would allow a deduction for insurance, I must pay
my share of any premium.
2. I acknowledge having been advised
of my rights to extended insurance coverage at group rates pursuant to the
Family Medical Leave Act. I elect
to participate in (if applicable):
Life
Health
Disability
Dental
* I understand that the
current rates are subject to the same changes applicable to active
employees.
3. I elect not to participate
in:
Health
Dental
Life
Disability
* If you chose not to elect
extended insurance coverage, please go to item number 8.
4. I acknowledge that I must make
monthly payments in the amount of $
------------ payable
to
and it is my responsibility to guarantee
(School District)
delivery of said
payment to (office address):
by the 15th of each month
preceding the covered month.
5. I acknowledge my responsibility to
inform, as applicable, my spouse and dependents of this benefit and the
responsibility thereunder.
6. I acknowledge that if I am granted
an unpaid leave which extends beyond the 12 weeks of FMLA leave, I will be
required at the conclusion of the month in which the FMLA leave concludes to pay
the full premium for any insurance I elect to continue during the
leave.
Employee Signature
Date:
ATT.
3
MEDICAL LEAVE
REQUEST
Employee’s Name
Date
Job Title
District
-------------------------------------------------------------------------------------------------------------
REASON FOR LEAVE:
LEAVE
REQUESTED:
From:
Date
To:
Date
Total Number of Days
Requested:
Indicate Regular Work
Hours:
Employee Signature:
Date:
-------------------------------------------------------------------------------------------------------------
PLEASE CIRCLE AND
SIGN:
This leave has been
approved
Yes
No
Supervisor’s
Signature
-------------------------------------------------------------------------------------------------------------
I recommend this approved
leave: ( ) With Pay
With Pay
# Days Available
( ) Without Pay
Authorized Signature
ATT. 4
SUPERINTENDENT OF
SCHOOLS
SCHOOL ADMINISTRATIVE UNIT
#53
267 Pembroke
Street
Pembroke, New
Hampshire 03275
REPORTING LEAVE
FORM
SCHOOL YEAR SCHOOL DISTRICT
Employee’s Name:
I request: Emergency Bereavement
Other (check one)
FOR
THE FOLLOWING REASONS:
LEAVE
ON THE FOLLOWING DATE(S):
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I request Personal Day(s) leave and certify that my request is being made for religious, family, medical, legal, death, or business reasons.
I also certify that this day(s) shall not be taken for gain nor to extend a holiday, weekend, or vacation.
LEAVE
ON THE FOLLOWING DATE(S):
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I request: Professional
LEAVE ON THE
FOLLOWING DATE(S):
FOR THE
FOLLOWING REASONS:
I estimate that there will be a cost involved of: (If applicable)
Transportation
No. of miles
@
per mile = TOTAL $
Meals & Room
TOTAL $
Tuition (Other)
TOTAL $
GRAND TOTAL
$
NOTICE:
Receipts for expenses MUST BE submitted before payment can be processed unless otherwise indicated in master agreement.
RECOMMENDED
NOT RECOMMENDED
Employee Signature
APPROVED DENIED
Principal
ATT. 5
CERTIFICATION OF PHYSICIAN
OR PRACTITIONER
(Family and Medical Leave
Act of 1993)
1. Employee’s
name:
2. Patient’s name (if other than employee):
3.
Diagnosis:
4. Date condition commenced:
5. Probable duration of condition:
6. Regimen of treatment to be prescribed (indicate number of visits, general nature and duration of treatment, including referral to other provider of health services. Include schedule of visits or treatment if it is medically necessary for the employee to be off work on an intermittent basis or to work less than the employee’s normal schedule of hours per day or days per week):
a) By physical or
practitioner:
IF THIS CERTIFICATION RELATES TO CARE FOR THE EMPLOYEE’S SERIOUSLY-ILL FAMILY MEMBER, SKIP ITEMS 7, 8 AND 9 AND PROCEED TO ITEMS 10 THRU 14 ON REVERSE SIDE. OTHERWISE, CONTINUE BELOW.
Check Yes or No below, as appropriate.
Yes No
7. Is inpatient hospitalization of the employee required?
8. Is employee able to perform work of any kind? (If “NO” skip item 9)
9. Is employee able to perform the functions of employee’s position? (Answer after reviewing statement from employer of essential functions of employee’s position, or, of none provided, after discussing with employee.)
10. Signature of physician or practitioner:
11. Type of
practice (field of Specialization, if any):
12.
Date:
ATT. 6
RETURN FROM LEAVE
FORM
TO BE FILLED OUT BY
SUPERVISOR:
ABSENT:
From: Date
To: Date
Total
Number of Working Days Absent:
( ) Approved
( ) Not Approved
Signature:
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TO BE FILLED OUT BY
EMPLOYEE:
( ) Resumed Normal Work Schedule
( ) Resumed Modified Duty
(Explain)
( ) Other (Explain)
Doctor’s Note Yes No
Date:
Employee
Signature: