ShawanoSchool District

FAMILY/MEDICAL LEAVE ACT

Leave Request Form

Which Employees Are “Eligible” to Take Leave Under the FMLA? (State Statutes 825.110).

(a)An “eligible employee” is one who has been employed by the employer for at least 12 months, has been employed and worked for at least 1250 hoursduring the last 12-monthsand is employed at a worksite where 50 or more employees are employed within a 75 mile radius.

(b)If an employee is maintained on the payroll for any part of the week, the week is counted as a week of employment (except that an employee who begins work after the first working day of a calendar week and who terminates employment before the last day of the week is not counted).

(c)The 1250 hours of service (actual hours worked in the previous calendar year) is determined according to the principles established under the FMLA. Exempt employees are presumed to have met the 1250 hours of service required for eligibility if they have worked for the employer at least 12 months.

The Federal Leave allows up to 12 weeks of leave. There is no substitution for accumulative paid leave.

Wisconsin Family and Medical Leave Law

•Up to two (2) weeks of leave in a calendar year for the care of a child, spouse or parent with a serious health condition. Two (2) weeks of State Family Medical Leave Act is considered a part of the total of 12 weeks that are available to employees. Employees may substitute available cumulative paid leave (sick leave) for up to two (2) weeks. To be eligible, the employee needs to have been paid for work for at least 1000 hours in the last 52 weeks.

How Much Leave Time is Available Under the FMLA for Child Rearing?

(a)The State of Wisconsin allows six weeks of leave under the Family Medical Leave Act. This six weeks is a part of the total of twelve weeks allowed for the Federal Leave. Therefore, an employee may take a total of 12 weeks of leave under the Family Medical Leave Act. Employees may substitute up to six weeks of cumulative paid leave (sick leave) as a part of the State Family Medical Leave Act.

(b)The Federal Family Medical Leave Act stipulates that 12 weeks of leave may be allowed under the Family Medical Leave Act. There is no substitution for accumulative paid leave under the Federal law. Six weeks of State Family Medical Leave Act is considered a part of the total of 12 weeks that are available to employees.

An employee must provide the employer with at least 30 days’ advance notice if the leave is foreseeable.

MEDICAL CERTIFICATION IS REQUIRED FOR ALL LEAVES.

Reason for FMLA request:______

______

Date(s) leave will be taken:______

Return date:______

Previous FML taken (approximate dates):______

School/Assignment:______

Name:______Date of Request:______