GCCBC
EPSOM SCHOOL DISTRICT
Family and Medical Leave Act of 1993
PURPOSE: To set forth proposed guidelines for processing employee request for any type of leave in accordance with the Family and Medical Leave Act of 1993.
PROCEDURES:
I. Family and Medical Leave
A. The Family and Medical Leave Act (FMLA) of 1993 requires that job-protected leave of up to 12 calendar weeks in a 12-month period be granted to employees under the following circumstances:
1. For the birth and first year care of the employee’s child or placement of a child with the employee for adoption or foster care.
2. For the care of the employee’s spouse, child or parent with a serious health condition.
3. For the employee’s own serious health condition.
Employees are eligible if they have worked for at least one year prior to the time leave is requested and for 1250 hours over the previous 12 months. The FMLA provides that the district may establish guidelines relative to administration of the required leave. Those guidelines are set forth below (B through L). A full copy of the text of the Family and Medical Leave Act of 1993 is available at the SAU #53 Central Office.
B. The 12-month period to be used in calculating an employee’s entitlement to family or medical leave will be the fiscal year July 1 through June 30, therefore employees need to re-apply for FMLA leave with their principal/supervisor prior to the beginning of each fiscal year for all classifications of employees.
C. All FMLA leave time will be processed with a Family Medical Act request form (ATT: 1).
APPROVED: March 1, 1994
AMENDED: February 6, 1996
D. The SAU will follow FMLA (1993) guidelines in the granting and scheduling of all leave requests, both non-intermittent and intermittent.
E. An employee may use any applicable paid leave (sick, personal or vacation) towards the 12-week FMLA leave entitlement in circumstances involving the employee’s own serious health condition. In FMLA leave-qualifying circumstances pertaining to first year care of child/adoption/serious health condition of family member, the employee may use paid personal and vacation leave toward the 12 weeks FMLA entitlement. In these circumstances, accumulated paid sick leave may only be used if the employee’s supervisor grants permission in writing prior to the beginning of said leave once the need for training, part-time and temporary help has been determined.
F. When eligible, intermittent leave or reduced leave schedules of a 1/2 workday minimum will be granted for a serious health condition provided the employee’s health care provider certifies this schedule as medically necessary. If an eligible employee requests foreseeable intermittent leave or a reduced work schedule for planned medical treatment for the employee or a family member, the SAU may temporarily transfer the employee to an available alternative position with equivalent pay and benefits.
G. Employees must give 30 days notice of the need for FMLA leave when it is foreseeable for the birth or placement of a child, or for planned medical treatment. Reasonable effort must be made to schedule leave so as to minimally disrupt the SAU’s operations.
H. FMLA leave for birth or placement of a child for adoption or foster care in the employee’s home may only be taken on a continuous basis.
I. For the duration of FMLA leave, all applicable insurance (health, dental, life, disability) coverage will be maintained and district contributions to premiums will continue. If an employee provides notice of intent not to return to work from the leave or fails to return from leave as scheduled, these employees would be allowed to continue any insurance benefits that covered by COBRA guidelines at their own expense (ATT. 2).
J. Upon return from FMLA leave, employees will be restored to their original or equivalent position with equivalent pay, benefits and other employment terms. The use of FMLA leave will not result in the loss of any employment benefits that accrued prior to the start of an employee’s leave.
K. The SAU will require periodic reports including medical certification in the event of a serious health condition from an employee on FMLA leave regarding the employee’s status and intent to return to work.
L. Employees returning to work after taking FMLA leave for a serious health condition will be required to submit medical certification of their fitness to work.
II. Sick Leave
A. While it is not always possible to obtain advance approval for sick leave requests, authorization for scheduled appointments and planned medical procedures should be requested in advance using a Medical Leave Request form (ATT. 3). If the length of the disability is not immediately known, the slip may be marked *FOR NOTIFICATION PURPOSES* at the top of the form and include the expected length of absence to the best of the supervisor’s knowledge. It need not be signed by employee if it is "For Notification Purposes."
B. When the employee returns to work, he/she should report to the supervisor to complete a Return from Leave slip. At this time the supervisor can make any appropriate inquiries or comments, and obtain the employee’s signature.
C. The slip should then be signed by the principal/supervisor who should ensure that appropriate documentation is attached when required.
D. The leave slip should then be forwarded to the SAU office for final action.
III. All Other Paid
A. The leave category should be provided on the leave slip if other paid leave (vacation, personal, emergency, etc.) is being requested.
B. Application for paid leave should be made through the principal/supervisor on Reporting Leave/FMLA Forms.
C. The Superintendent (certified employees) and the Business Administrator (non-certified employees) are the final approving authorities for paid leave requests.
D. The completed form shall be retained by the SAU office for audit purposes, and one copy given to the employee.
E. Administrator’s Leave requests shall be routed to the Superintendent for approval.
IV. Leave of Absence Without Pay
A. Leaves without pay should also be processed using the Reporting Leave/Medical/FMLA Leave forms with whatever supplemental materials may be appropriate. The number of days requested should be entered and noted "without pay." A reason for the request must be given and shall be accompanied by:
B. A physician’s medical certification (ATT. 5) will be required for leaves without pay for the employee’s own serious health condition or that of a spouse, parent or child under the terms of the Family and Medical Leave Act.
C. A separate Return from Leave form (ATT. 6) will be necessary to reinstate the employee at the conclusion of the leave.
D. All materials shall be forwarded through the principal/supervisor for their approval and then to the SAU office for final action.
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
(White Copy - SAU Office, Yellow Copy - Supervisor, Pink Copy - Employee)
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.
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
(White Copy - SAU Office, Yellow Copy - Supervisor, Pink Copy - Employee)
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):
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):
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:
TO BE FILLED OUT BY EMPLOYEE:
( ) Resumed Normal Work Schedule
( ) Resumed Modified Duty (Explain)
( ) Other (Explain)
Doctor’s Note Yes No
Date:
Employee Signature:
(White Copy - SAU Office, Yellow Copy - Supervisor, Pink Copy - Employee)