Hopkinton Public Schools

Hopkinton Public Schools

Family Medical Leave Request Form

All HTA Unit A & Unit C Employees

Subject to the conditions set forth in the Hopkinton School Committee Policy GCCC Family and Medical Leave Policy, the School Department will provide eligible employees with up to twelve weeks of unpaid family/medical leave ("FMLA leave") in a twelve-month period for one or more of the following reasons:

·  The birth of a child and in order to care for the newborn;

·  The adoption or placement of a child for foster care with the employee;

·  To care for a child, spouse, or parent with a serious health condition;

·  Because of the employee's own serious health condition that makes the employee unable to perform the essential functions of his/her position;

·  Any qualifying exigency arising out of the fact that the spouse, son, daughter, or parent of the employee is on active duty, or has been notified of an impending call to active duty status, in support of a contingency operation.

Additionally, an eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered service member who is recovering from a serious illness or injury sustained in the line of duty on active duty is entitled to up to 26 weeks of leave in a single 12-month period to care for the service member.

A "serious health condition" means an illness, injury, impairment, or physical or mental condition that involves either: (1) inpatient care, including any period of incapacity or any subsequent treatment; or (2) continuing treatment by a health care provider. Further explanation of circumstances constituting a "serious health condition" is contained in the Medical Leave Certification Form that must be completed by a health care provider to certify the need for leave when an employee requests a leave under FMLA or is placed on a leave by the employer under FMLA.

In terms of using sick time for this leave, please note that in accordance with Article XIII of the Agreement between the Hopkinton School Committee and the Hopkinton Teachers Association, as with FMLA leave, maternity leave is unpaid leave. However, if your physician declares a short-term disability, you will be eligible for sick leave for the period of time designated by your physician. If a maternity related disability exceeds eight weeks, the Superintendent may request a physician’s opinion at School Committee expense.

If this is a maternity leave request, you must provide at least two weeks’ written notice before your anticipated date of departure and indicating your intention to return, per the teachers’ contract.

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Full Name Date of Request Social Security Number

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Reason for request of leave

Leave is requested to begin ______and continue until ______

Date Date

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Employee’s Signature Date

In order to consider this request, you must provide documentation from your healthcare provider that includes the medical facts supporting the request and the date on which the condition commenced or will commence and the probable duration of your incapacity. If this is a request for maternity leave, documentation must include your healthcare provider’s estimate of your delivery date. o Check if this documentation is attached to this request.

Employees on maternity leave must provide this office, within seven (7) days of delivery, documentation from a physician stating the actual delivery date and the number of days or weeks for which the employee will be unable to return to work after delivery.

Revised 12/2008