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435. ATTACHMENT
1
John Castrovinci
Director of Human Resources
Kathleen Kline• Confidential Administrative Assistant• Extension 35014, klinek@eastonsd.org
Lori Fulmer• Confidential Administrative Assistant• Extension 35057, fulmerl@eastonsd.org
REQUEST FORM FOR FAMILY MEDICAL LEAVE OF ABSENCE
Name: _______________________________ Building: _____________________
Position: ______________________________ Date: ________________________
I hereby apply for a Family and Medical Leave of Absence for the following reasons:
_____
The birth and/or first year care of my child:
Attach doctor’s note.
Provide estimate as to the amount of leave time needed.
_____
The placement of a child with me for adoption or foster care:
Attach documentation.
Provide an estimate as to the amount of leave time needed.
_____
The care of my child, spouse, or parent who has had a serious health
condition:
Attach medical documentation with the date and nature of the
illness.
Provide an estimate as to the amount of leave time required.
_____
My inability to perform the functions of my position because of a serious
health condition. Attach medical certification stating the date the serious
health condition commenced, the reasons for the leave, and the inability of
the employee to perform the functions of his/her position.
_____
Military caregiver leave to care for a covered servicemember, including a
covered veteran, with a serious injury or illness:
435. ATTACHMENT
2
Attach medical documentation with the date and nature of the
illness.
Provide an estimate as to the amount of leave time required.
_____
Qualifying exigency leave arising out of the fact that my spouse, son,
daughter, or parent is on active duty military service in a foreign country,
or has been notified of an impending call or order to active duty military
service in support of a contingency operation:
Attach documentation.
Provide an estimate as to the amount of leave time needed.
Effective date of leave: _____________________________________________
Note: Please submit this form thirty (30) days in advance of the effective date of
the leave.
Estimated return to employment date: __________________________________
My request is for:
_______
Full time leave of absence
_______
Intermittent Leave
Note:
Medical certification must state the dates on which treatments are to be
given and the duration of such treatments.
Signature: ______________________________
Street Address: __________________________
_______________________________________
Date: __________________________________
Approved by:
__________________________________
Administrator’s Signature
Approved at Board Meeting:
_____________________
Date of Board Meeting
Revised 05/27/10