409.3E2 - Employee Family and Medical Leave Request Form

Date:__________
I, _____________________________________, request family and medical leave for the following reason:
(check all that apply)
_____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; or
_____because I am seriously ill and 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; ___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; ___next of kin of a covered service member with a serious injury or
illness.

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.

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

I request that my family and medical leave begin on _______________ and I request leave as follows: (check one)
_____continuous
           I anticipate that I will be able to return to work on _________.
_____intermittent leave for the:
          _____birth of my child or adoption or foster care placement subject to agreement by the district;
          _____serious health condition of myself, spouse, parent, or child when medically necessary;
_____because of a qualifying exigency arising out of the fact that my ___ spouse; ___ son or daughter; ___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; ___next of kin of a covered service member with a serious
injury or illness.

Details of the needed intermittent leave:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

I anticipate returning to work at my regular schedule on _________.
_____reduced work schedule for the:
          _____birth of my child or adoption or foster care placement subject to agreement by the district;
          _____serious health condition of myself, spouse, parent, or child when medically necessary;
_____because of a qualifying exigency arising out of the fact that my ___spouse; ___ son or daughter; ___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; ___next of kin of a covered service member with a serious
injury or illness.

Details of needed reduction in work schedule as follows:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

I anticipate returning to work at my regular schedule on _________.

I realize I may be moved to an alternative position during the period of the family and medical intermittent or reduced work schedule leave. I
also realize that with foreseeable intermittent or reduced work schedule leave, subject to the 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 will be
deducted from moneys owed me during the leave period. If no monies are owed me, I will reimburse the school district by personal check or
cash for my contributions. I understand that I may be dropped from the employer-sponsored benefit plans for failure to pay my contribution.

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.

I acknowledge that the above information is true to the best of my knowledge.

Signed _______________________________________________

Date ____________________

If the employee requesting leave is unable to meet the above criteria, the employee is not eligible for family and medical leave.

Legal Reference:
29 U.S.C. §§ 2601 et seq.
29 C.F.R. § 825.
Iowa Code §§ 20; 85; 216; 279.40.
Whitney v. Rural Ind. School District, 232 Iowa 61, 4 N.W.2d 394 (1942).

Cross Reference:
409.2 Employee Leave of Absence

Approved 11-15-21
Reviewed 5-15-23  
Revised  5-15-23