Western Dubuque County Community School District
Employee Family & Medical Leave Request Form
4/19/2021

Western Dubuque Community Schools

Employee Family & Medical Leave Request Form

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Date: *
(mm/dd/yyyy)
*
Employee First Name
*
Employee Middle Initial
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Employee Last Name

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I request family and medical leave for the following reason(s):

(check all that apply)

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for the birth of my child  
for the placement of a child for adoption or foster care  
to care for my child who has a serious health condition  
to care for my parent who has a serious health condition  
to care for my spouse who has a serious health condition  
because I have a serious health condition and am unable to perform the essential functions of my position  
because of a qualifying exigency arising out of the fact that my spouse; son or daughter; or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves  
because I am the spouse; son or daughter; parent; or next of kin of a covered service member with a serious injury or illness  

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I acknowledge my obligation to provide medical certification of my serious health condition or that of a family member in order to be eligible for family and medical leave within 15 days of the request for certification.

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I acknowledge receipt of information regarding my obligations under the family and medical leave policy of the school district.

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I request that my family and medical leave begin on:
Date: *
(mm/dd/yyyy)

I anticipate I will be able to return to work on:

Date: *
(mm/dd/yyyy)

I request leave as follows:

*
continuous  intermittent  
reduced work schedule  

My intermittent leave is for:

the birth of my child or the adoption or foster care placement subject to agreement by the district  
the serious health condition of myself, parent, or child when medically necessary  
because of a qualifying exigency arising out of the fact that my spouse; son or daughter; or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves  
because I am the spouse; son or daughter; parent; or next of kin of a covered service member with a serious injury or illness  
choose one

Comments regarding intermittent leave request:

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My reduced work schedule is for:

the birth of my child or adoption or foster care placement subject to agreement by the school district.  
serious health condition of myself, parent, or child when medically necessary.  
because of a qualifying exigency arising out of the fact that my spouse; son or daughter; or parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves  
because I am the spouse; son or daughter; parent; or next of kin of a covered service member with a serious injury or illness  

Comments regarding request for reduction in work schedule:

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I realize I may be moved to an alternate position during the period of the family and medical leave intermittent or reduced work schedule leave. I also realize that with forseeable intermittent or reduced work schedule leave, subject to requirements of my health care provider, I may be required to schedule the leave to minimize interruptions to school district operations.
While on family and medical leave, I agree to pay my regular contributions to employer sponsored benefit plans. My contributions shall be deducted from moniess owed me during the leave period. If no monies are owed me, I shall reimburse the school district by personal check (cash) for my contributions. I understand that I may be dropped from employer-sponsored benefit plans for failure to pay my contribution.

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I agree to reimburse the school district for any payment of my contributions with deductions from future monies owed to me or the school district may seek reimbursement of payments of my contributions in court.

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I acknowledge that the above information is true to the best of my knowledge.
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Employee signature (typed is sufficient)

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Routing Instructions
Please route this form to the Department Head/Principal for approval and then the form is automatically routed to the Superintendent.
Complete the information below to route your form. * Indicates Required Fields
Your Name:
* Your E-mail: *
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Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.