FAMILY & MEDICAL LEAVE ACT (FMLA) COVER SHEET
Please return this completed form via email, fax, mail or drop off for FMLA eligibility verification.
I understand that to be eligible for protected leave under the Family & Medical Leave Act, I must have been employed by the School
District of Philadelphia for a cumulative total of 12 months AND have physically worked a minimum of 1250 hours during the 12
months before the FMLA beginning date.
______________________________________________________ _________________________
NAME EMPLOYEE ID#
______________________________________________________
STREET ADDRESS
______________________________________________________
CITY, STATE, ZIP CODE
PLEASE COMPLETE THE FOLLOWING INFORMATION
:
Telephone # (Cell or Home) ________________________________________________________________________
Position:
______________________________________
Work Location:
____________________________________
(SCHOOL OR OFFICE)
Beginning date for FMLA protection: __________________________________________
*This date should match the first date you were absent or will be absent for the type of leave you will take.
Type of leave you are requesting FMLA protection for:
______Personal illness
______Illness in family
*Relationship of family member to you:________________________________________ *Age (if child):______________
______The birth of your child ______Adoption/foster care placement**
______Serious injury or illness of Servicemember** ______Qualifying Military Exigency (unpaid leave)** _____Military Caregiver**
**These FMLA requests have specific certification forms that you will receive if you meet the FMLA eligibility requirements.
How will you take your leave? :
____ consecutively (an absence of more than 3 consecutive work days)
____ intermittently (non-consecutive absences)
**If your consecutive leave will last for less than 12 weeks, your FMLA request will be processed for intermittent leave.
_____ Check if you want your FMLA notification letters sent to your SDP email address
EMAIL ADDRESS:______________________________________________
OR
_____ Check if you want your FMLA notification letters mailed to your home
DATE CERT REQ’D/ REC’D
______________
NEW FMLA YR _____
RE-CERT _____
FOR OFFICE USE ONLY
Office of Talent
Employee Health Services
440 N. Broad Street, Suite 134
Philadelphia, PA 19130
Main office number: 215.400.4660
Fax: 215.400.4661
CONTACT: fmla@philasd.org
