Employee Request for Leave Form


Reason for request

  • A Human Resource Administrator will contact you. Please be prepared to provide the placement and medical authorization.
  • Date of Leave/ Date of Return

Basis of Leave


  • Employees eligible for family and medical leave may take up to 12 weeks of unpaid leave. Upon request for family and medical leave for an employee’s serious health condition or that of a spouse, parent, or child, and at 30-day intervals thereafter, the employee shall provide medical certification of the illness or disability. To be eligible for family and medical leave, the employee must also have been continuously employee by the District for the past 12 months, and must have worked at leave 1,250 hours during the 12-month period prior to commencement of the leave. An employee seeking to return to work after a leave for his or her own serious illness, must provide a medical certification of the employee’s ability to perform essential job functions before being allowed to resume work.Employees are required to use family and medical leave concurrently with paid leave and with temporary disability leave if applicable.

  • I hereby agree that while I am on leave, I will continue to pay my share of health insurance premiums unless I elect to discontinue such coverage.  If I fail to return to work at the end of the leave period, I agree to reimburse the District for the cost of health benefits provided during my leave, unless I fail to return to work because of the continuation,onset, or recurrence of a serious health condition, or because of other circumstances beyond my control.  If I am unable to return to work because of a serious health condition, I will provide medical certification from the appropriate health care provider stating that I am unable to perform the functions of my job on the date that my leave expires.  I understand that I may not be allowed to resume my job until I provide such medical certification.