DATE:
RETURN 1 COPY TO MICHELE HARTNETT; KEEP 1 COPY FOR YOUR RECORDS
EMPLOYEE:EMPID:
Leave requested (please circle one that applies): Maternity Medical Family
Leave date effective: ______Return to work date effective:______
FMLA is in effect for a maximum ofsixty contracted work days for ten-month employees, twelve work weeks for twelve-month employees. I am in receipt of the following documents:
- FMLA & Donated Leave policies
- FMLA Notice of Rights & Eligibility and/or FMLADesignation form
- FMLA Medical Certification form with job description attached – give to attending physician and fax completed form to Michele Hartnett, 302.992.7824
- Short-term Disability letter
- Disability Insurance Program checklist and activity log
- Leave of absence overview
FMLA ELIGIBLE EMPLOYEES
If accrued sick leave is available, I am withholding accrued sick days: 0 1 2 3 4 5
(12-month employees only)
If accrued vacation leave is available, I am withholding accrued vacation days: 0 1 2 3 4 5
My signature below is written acknowledgement that I am in receipt of the documents above and that I agree to:
-Provide medical notes from my attending physician disabling me from work and returning me to work with the effective date on each note.
-Email Susie Bonis within 30 calendar days of the birth of my child/ren if I am adding my child/ren to my medical/RX plans. I must email the full name and birth date of my child/ren.
-Providea copy of my child’s birth certificate and copy of my child’s social security card when both documents are received.
-Keep my supervisor/s and Michele Hartnett informed of any extension of leave and return date.
-Email return to work date.
-If an extension of leave is requested beyond the FMLA expiration date, the extended leave will be in force for the entire school year.
-If an extension of leave is requested beyond the FMLA expiration date, the employee may purchase benefits or request a HIPAA certificate for proof of prior coverage.
Teachers & Paraprofessionals - If your continuing license expires during your leave of absence, you are responsible for renewing your license prior to return from leave. Contact Debra Davenport if you have questions regarding your license.
My signature below certifies I am in receipt of and have read and understand the policies and procedures contained in the documents included with this document.
______
SignatureDate
Please write your leave dates, sign and return one copy via fax, email or mail to:
Michele Hartnett - FAX: 302.992.7824
Red Clay Consolidated School District
1502 Spruce Avenue
Wilmington, DE 19805