Certified Staff Initial Request for FMLA

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Fill out this form and submit for your request for FMLA.

Per Federal FMLA, paperwork will be provided within 5 days of request.

FMLA is job-protected unpaid leave up to 60 days in a one-year period. The BOE defines a one-year period as a fiscal year beginning July 1 and ending June 30.

Paid FMLA for Yourself: You may use your available sick and personal time.

Paid FMLA for a Family Member (Per the HEA & Administrator Contracts): You may use up to 15 paid sick days to care for a family member plus available personal time.

Email *

Requestor's First and Last Name: *

Requestor's Position: *

Requestor's Building/School: *

Today's Date: *

YYYY

Select if applying for Self *

Birth of a child / Maternity

Placement of a child with you for adoption or foster care, and to bond with the newborn or newly-placed child

Your own serious health condition

Not Applicable

Select if applying for Qualified Family Member (select one) *

Parent

Child under age 18

Child 18 years or older and incapable of self-care because of a mental or physical disability

Spouse

Not Applicable

Select if applying for Military Family Leave *

Qualifying Exigency arising out of the covered active duty of my spouse, parent, or child

Military caregiver leave for my spouse, parent, child, or next of kin who is a covered service member

Military caregiver leave for my spouse, parent, child or next of kin who is a covered veteran

Not Applicable

Type of leave you are requesting (Select one) *

Consecutive (blocks of time with a documented start/anticipated end date)

Intermittent (periodic/occasional absences related to your approved FMLA request

Anticipated Start Date of your FMLA Leave *

YYYY

A copy of your responses will be emailed to the address you provided.

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