Wethersfield Public Schools

Family Medical Leave Request Form

Subject to the conditions set forth by the Wethersfield Public Schools 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.

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 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.

Please complete the bottom portion of this document and submit to Human Resources, 127 Hartford Ave., Wethersfield, CT 06109. Upon receipt of your request, a packet of information including the Certification of Healthcare Provider for Employees Serious Health Condition (form WH-380-E) or Family Members Serious Health Condition (form WH-380-F) will be forwarded to you. In order for your request for FMLA to be considered, your healthcare provider must complete, sign and return the Certification of Healthcare Provider for Employees Serious Health Condition(form WH-380-E) or Family Members Serious Health Condition (form WH-380-F) to this office by the due date listed.

______

Full Name Date of Request

______
Reason for Request of Leave

Leave is requested to begin ______and continue through ______

Date Date

______

Employee’s Signature Date

For HR Office Use

Request Received: ______Documents Sent: ______

Date Date

Completed WH-380-e/f) Received: ______

Date

8/26/16 Z:\Kathy___.__\Leave-FMLA-Sick-Admin\fmla_form.docx