School
District 4J
Department of Human Resources / Leave of Absence Request Form
Contact HR Leave Coordinator if you have any questions.
(541) 790-7660
Part One (1): User Instructions
A Leave of Absence Request Form is required for all leaves including family or medical absences of more than five (5) working days or any bereavement leave.
- Complete all sections of Part One (1). Read and sign section F.
- Give the completed form to your Principal/Administrator/Supervisor to review and sign Part Two (2).
- Make a copy for your records.
Return completed forms to: Human Resources Department Attention: HR Leave Coordinator
Electronically at:
/ OR / Eugene School District 4J
200 North Monroe Street
Eugene, OR 97402
Your leave request is due as soon as you become aware of your need for leave. If you cannot obtain the appropriate signature in Part Two (2) within twenty-four (24) hours, contact the HR Leave Coordinator to advise him/her of your leave request.
Provide mandatorysupporting documentation to the HR Leave Coordinator within 15 calendar days of your request, or before your leave begins, whichever is later. Contact the HR Leave Coordinator at (541) 790-7660 if you have extenuating circumstances.
Section A: Personal Information / Employee Group (please check one)
Classified / Licensed / Admin/Supervisor/Prof.
Name: / Today’s Date:(mm/dd/yyyy)
Home Address:
Street / City / State / Zip
Home Phone: / Work Phone:
Preferred Email:
Bldg/Department: / Employee Number:
Current FTE/Hours: / District Hire Date:
Section B: Dates and Schedule of Requested Leave
Leave Start Date: / Leave Return Date:
Full Time Leave
(all of my assignment) / Part Time Leave*
Working FTE/Hours Requested:
Intermittent Leave**: When applicable under special conditions.
Footnotes:
* Part Time Leave – working a reduced schedule
** Intermittent Leave – leave taken on an irregular basis, occurring occasionally or at regular or irregular intervals.
Section C: Reason(s) for Leave / Mandatory Supporting Documentation
Medical Leave (own serious health condition) / Medical Certification Form
Family Medical leave (immediate family member’s serious health condition) Spouse, Parent, Biological, Adopted or Foster Child, Parent-in-Law, Same-sex domestic partner, Grandparent, or Grandchild / Family Medical Certification Form
Parental Leave
for birth of baby. Due Date:
for adoption of a child or placement of foster child / Certification of Placement
Pregnancy Disability Leave (serious pregnancy disability) / Medical Provider Note
Personal Leave / Reason for Request (Section E)
Professional Leave / Reason for Request (Section E)
Part-Time Leave / Working: / FTE
(Licensed and Admin/Prof/Supervisor employees only)
Bereavement Leave for: / Please provide relationship of deceased.
Military Leave / Copy of Service Orders
Other, please describe:
Section D: Paid Leave
Medical Leave:An employee may elect to use their accrued sick, miscellaneous/personal, accumulated miscellaneous/personal, discretionary, compensatory, and vacation time.
Yes, I would like to use my accrued leave during this Medical Leave
No, I do not want to use my accrued leave during this Medical Leave
Family Leave (Family Medical, Parental or Pregnancy Disability Leave): An employee may elect to use their family, accumulated family, sick, miscellaneous/personal, accumulated miscellaneous/personal, discretionary, compensatory, and vacation time will be used. Use of accrued family and accumulated family leaves will be exhausted first before other leave will be used. Some leave types only applicable under FMLA or OFLA.
Yes, I would like to use my accrued leave during this Family Leave
No, I do not want to use my accrued leave during this Family Leave
If parental leave, will your spouse be taking time off?
If yes, my spouse works for:
This family medical leave is for my:
Spouse, Parent, Biological, Adopted or Foster Child, Parent-in-Law, Same-sex Domestic Partner, Grandparent, or Grandchild.
Section E: Personal and Professional Leave Requests ONLY
Please outline your plans for Personal or Professional/Career Development leave below:
Please attach an additional sheet if necessary.
Section F: Employee Signature – Read the following rights and responsibilities carefully before signing.
- I understand that I am required to provide supporting documentation, medical or otherwise, directly to the HR Leave Coordinator, within 15 days of this request or before my leave begins, whichever is later. I understand that failure to provide adequate and timely certification will disqualify my leave from job protection under the Federal Family Medical Leave Act (FMLA) and the Oregon Family Leave Act (OFLA) statutes and that my leave will be denied in accordance with § 825.305 and 839-009-0250.
- I understand that I am responsible for ensuring my absences are reported according to my department and District policy. I will check with my Supervisor/Administrator if I am uncertain of my responsibilities or need assistance reporting my absences while on leave.
- I understand that if I do not return to work, I may be requested to reimburse the District for any District-paid group health insurance that I was provided while on the unpaid portion of my leave of absence unless my failure to return to work is due to a continuation or reoccurrence of a serious health condition or other circumstances as permissible by Federal and State law.
- I certify that the information provided on the previous two pages is accurate and correct.
- I have reviewed the attached “Information for Employees Considering a Leave of Absence” (pages 5 and 6 attached) and understand all the information provided.
Employee Signature / Date(mm/dd/yyyy)
If my request is sent via District email then my email shall serve as my electronic signature on this leave request.
Part Two (2): Supervisor/Administrator – Please fax this form to the HR Leave Coordinator at (541) 790-7665 AND send the original by District Mail to Human Resources.
My signature indicates that I have reviewed the leave with this employee. I have explained the expectations for absence reporting and arranging a substitute, if applicable. I have directed him/her to forward required documentation directly to the HR Leave Coordinator.
Supervisor Name / Signature / Date(mm/dd/yyyy)
(Please Print)
I may forward this request via District email to the HR Leave Coordinator, and if I approve this request via District email, my email shall serve as my electronic signature for this leave request.
Part Three (3): Human Resources Use
Leave eligibility determination and signatures:
Dates Requested: / through / Return:
FMLA Eligible: / Yes / No / 12mo/1250hrs/reason
Dates: / through
OFLA Eligible: / Yes / No / 6mo/ave 25 hrs wk/reason
Dates: / through
Comments:
Leave History:
School Year: / Leave Used: / In Accordance with:
Accrued Leaves as of:
Sick: / Total Hours Available:
Personal:
Accm Personal: / Total Available Days:
Family: / at / FTE
Accm Family: / Date Paid Leave Ends: (excluding SLB)
Vacation:
Discretionary:
Comments:
HR Administrator Signature / Date
INFORMATION FOR EMPLOYEES CONSIDERING A LEAVE OF ABSENCE
LEAVE APPLICATION AND APPROVAL PROCESS
To assure you have a right to a leave and to retain your District employment rights during and upon return from leave, you must request and be approved for the leave. The request and approval is accomplished by:
1) Reviewing the Leave’s section of the Human Resource website at
2) Completing the attached Leave of Absence Request Form
3) Obtaining your supervisor's signed approval, and
4) Submitting the completed form to the HR Department for final processing and approval.
Leave types that may qualify for leave in accordance with the Federal Family and Medical Leave Act (FMLA) and/or the Oregon Family Medical Leave Act (OFLA) are:
1) Birth, adoption, or placement of a child (parental leave)
2) To care for your family member with a serious health condition (family medical leave)
3) To care for your own serious health condition (medical leave)
4) For pregnancy disability or parental care (pregnancy disability leave)
5) To care for your sick child who does not have a serious health condition, but requires home care
(sick child leave)
6) Military leave
NOTE: Your request for FMLA and/or OFLA medical (or family medical) leave must be supported by your (or your family member's) physician's opinion on the medical condition. If medical certification is not received in the time frame requested your leave will be denied.
If you qualify for FMLA and/or OFLA leave, you have additional rights. These rights include the ability to use your accumulated paid leave while on the leave, the right to take up to twelve (12) weeks of qualifying leave in a fiscal year, the right to continued District insurance contribution and, usually, the right to return to your position. The use of leave that qualifies under OFLA and FMLA will be concurrent with other paid and unpaid leave. To qualify for OFLA and FMLA leave you must apply and be approved for the leave prior to taking the leave except in cases of an emergency and then the application must be completed as soon as possible.
Laws and Contract Terms That May Impact Your Long-Term Leave Options and Decisions
Long-term Disability Income Replacement: Long Term Disability coverage is designed to provide income protection should you become partially or fully disabled on or off the job. You may file a claim if you are unable to continue working in full capacity due to a disability. If your claim is approved, you may receive up to 66.66% of your pre-disability gross income beginning 90 days after your date of disability. A claim may be started by following the instructions at
Sick Leave Bank: When you have used all of your accrued paid leave time you may be eligible for continued compensation through your membership in a sick leave bank. To determine your sick leave bank eligibility, see section 8.1.11 of the District/EEA Collective Bargaining Agreement, section 13.1.7 of the Distinct/OSEA Collective Bargaining Agreement, and section 8.E.10 of the District/4JA Statement of Understanding. For information about applying to the sick leave bank contact:
Licensed employees: Licensed Benefits Coordinator at (541) 790-7682
Classified employees: Classified Benefits Coordinator at (541) 790-7679
Administrative employees: Employee Benefits Manager at (541) 790-7675
If you qualify for sick leave bank days, you gain the benefit of continued compensation at your full daily rate for the number of days you are allocated. Sick leave bank is additional paid time to cover some, or all, of the gap between your available paid leave time and your eligibility for Long Term Disability (LTD) income replacement payments.
Collective Bargaining Contract Basis for Long-Term Leave
The long-term (generally more than five (5) days) unpaid leaves available to District employees are described in Article 9 of the District/EEA Collective Bargaining Agreement, in Article 14 of the District/OSEA Collective Bargaining Agreement, and Article 8.B of the District/4JA Statement of Understanding. District employees may have additional leave rights under the Federal Family and Medical Leave Act (FMLA) and the Oregon Family Leave Act (OFLA). These leave rights are in addition, but may be concurrent with, other shorter-term contract paid leave rights such as sick leave, family leave, personal leave, critical family illness leave, bereavement leave, legal leave, etc. These short-term paid leaves are described in the Article 8 of the District/EEA Collective Bargaining Agreement, in Article 13 of the District/OSEA Collective Bargaining Agreement, and Article 8.A of the District/4JA Statement of Understanding.
HEALTH INSURANCE AVAILABLE DURING A LEAVE
All Benefits-Eligible District Employees
There are limitations on your eligibility for the District health insurance plan you need to know if you are considering a long-term leave.
Paid Leave: While on paid leave (not sick leave bank) you continue to be eligible for the District monthly insurance contribution if you continue your monthly out-of-pocket contribution.
Unpaid Personal or Professional Leave: While you are on an approved unpaid personal or professional leave with the District, you lose eligibility for the District's health insurance plan; however, you may continue your coverage for up to 29 months by enrolling in the Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation coverage. COBRA is a federal law that requires all group health insurance carriers to allow an employee who is no longer eligible for active employee group health plan coverage to self-pay for the health insurance plan for up to 29 months. After COBRA rights have ended, the only health insurance plan available through the District carrier is a "portability" plan. More information on COBRA, Portability and other alternatives can be found on the 4J benefits web site: http: benefits end.
You will not regain eligibility for the District health insurance plan until you return to work in a benefits-eligible position. At that time you must submit new benefits enrollment forms similar to a new hire. Previous plans will NOT automatically reinstate.
CAUTION: Our current insurance carrier has strict rules regarding District retiree insurance eligibility, after taking a personal or professional (non-medical) leave. You will only be eligible for the District retiree insurance in the future if you return to regular employment and are covered on the District's insurance plan, prior to retirement.
Unpaid Medical Leave: While you are on approved unpaid medical leave you may be eligible to continue the District health insurance plan with the District contribution for the leave term (some restrictions apply) as long as you continue your employee contribution. See the EEA contract section 9.1, the OSEA contract section 13.1.8, or the 4JA statement of understanding section 8.B.4. You also may be eligible for the sick leave bank benefit. See the EEA contract section 8.1.11, the OSEA contract section 13.1.7, or the 4JA statement of understanding section 8.E.10.
Please contact the Employee Benefits Manager at (541) 790-7675 to obtain information and forms for continuing insurance and/or payment of premiums while on approved unpaid medical leave.
Leave of Absence Request Form Page 1 of 6
Revised 06/2012; Form Owner Human Resources; Form Location: http:/