The information provided in this document is applicable to civil service, bargaining unit covered, exempt
professional, and faculty employees. Human Resources (HR) provides this kit to assist in handling leave request
for medical leave, domestic violence leave, or various types of military leave, for the employee and the family
member’s situation. This document does not include all the details of the program discussed. Any issues that
are not addressed in the guide will be administered in accordance with various Federal, State and Edmonds
Community College Leave Regulations and Policies.
This kit may be used in conjunction with Reasonable Accommodation (RA) request. However, if this request for
medical leave is a Reasonable Accommodation (RA) request or part of a request, you may be requested to also
complete the appropriate RA request form. The Reasonable Accommodation policy may be found in the
U:Drive.
Depending on the reason for your leave, this kit will provide:
The leave request for:
Leave for the employee’s health condition
Leave for a family member’s health condition
Leave for birth or placement for adoption or foster child and care of child
Medical Leave, when the employee is not eligible for FML
Shared Leave
Leave for Domestic Violence
Leave for Care of a Service Member/Veteran
Exigency Leave
Edmonds Community College
Medical, Domestic Violence and various Military Leave Information Kit
Each of the above types of leave will have a corresponding Certification Form to be completed by a health care
provider, or other appropriate party. If the certification form is not included with this kit it is available by calling
your HR representative.
Please contact your Human Resources representative for assistance with this packet.
Basic Leave Entitlement
FMLA requires covered employers to provide up to 12 weeks of unpaid, job-
protected leave to eligible employees for the following reasons:
For incapacity due to pregnancy, prenatal medical care or child birth;
To care for the employee’s child after birth, or placement for adoption or
foster care;
To care for the employee’s spouse, son, daughter, or parent who has a
serious health condition; or
For a serious health condition that makes the employee unable to
perform the employee’s job.
EdCC uses a “forward rolling year” method of calculating the 12 workweeks.
You may take your leave in several blocks of time, on an intermittent basis or as
a reduced work schedule, if determined to be medically necessary by your
attending health care provider.
Under State leave rules a mother may be eligible for FML during the pregnancy
(and before delivery), based on her own medical need. The birth of the baby is
then considered a separate FML qualifying event allowing for up to 12 weeks
off to care/bond with newborn.
Military Family Leave Entitlements
Eligible employees with a spouse, son, daughter, or parent on active duty or call
to active duty status in the National Guard or Reserves in support of a
contingency operation may use their 12 week leave entitlement to address
certain military events, arranging for alternative childcare, addressing certain
financial and legal arrangements, attending certain counseling sessions, and
attending post-deployment reintegration briefings.
FMLA also includes a special leave entitlement that permits eligible employees
to take up to 26 weeks of leave to care for a covered service member/veteran
during a single 12 month period. A covered service member/veteran is a
current member of the Armed Forces, including a member of the National
Guard or Reserves, has a serious injury or illness hat occurred in the line of duty
on active duty that may render the service member/veteran medically unfit to
perform his or her duties for which the service member/veteran is undergoing
medical treatment, recuperation, or therapy; or is in outpatient status; or is on
the temporary disability retired list.
Benefits and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the employee
had continued to work. Failure to pay the employee portion of the premiums
within 30 days of the due date could result in cancellation of coverage. Upon
return from FMLA leave, most employees must be restored to their original or
equivalent positions with equivalent pay, benefits, and other employment
terms. Use of FMLA leave cannot result in the loss of any employment benefit
that accrued prior to the start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at least
one year, for 1,250 hours over the previous 12 months, and if at least 50
employees are employed by the employer within 75 miles.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or mental
condition that involves either an overnight stay in a medical care facility, or
continuing treatment by a health care provider for a condition that either
prevents the employee from performing the functions of the employee’s job, or
prevents the qualified family member from participating in school or other daily
activities.
Subject to certain conditions, the continuing treatment requirement may be
met by a period of incapacity of more than 3 consecutive calendar days
combined with a least two visits to a health care provider or one visit and a
regimen of continuing treatment, or incapacity due to pregnancy, or incapacity
due to a chronic condition. Other conditions may meet the definition of
continuing treatment.
Use of Leave
An employee does not need to use this leave entitlement in one block. Leave
can be taken intermittently or on a reduced leave scheduled when medically
necessary.
Employees must make reasonable efforts to schedule leave for planned medical
treatment so as not to unduly disrupt the employer’s operations. Leave due to
qualifying exigencies may also be taken on an intermittent basis.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave
while taking FMLA leave. In order to use paid leave for FMLA leave, employees
must comply with the employer’s normal paid leave policies.
Employee Responsibilities
Employees must provide 30 days in advance notice of the need to take FMLA
leave when the need is foreseeable. When 30 days notice is not possible, the
employee must provide notice as soon as practicable and generally must
comply with an employer’s normal call-in procedures.
Employees must provide sufficient information for the employer to determine
if the leave may qualify for FMLA protection and the anticipated timing and
duration of the leave. Sufficient information may include that the employee is
unable to perform job functions, the family member is unable to perform daily
activities, the need for hospitalization or continuing treatment by a health care
provider, or circumstances supporting the need for military family leave.
Employees also must inform the employer if the requested leave is for a reason
for which FMLA leave was previously taken or certified. Employees also may be
required to provide a certification and periodic recertification supporting the
need for leave.
Employer Responsibilities
Covered employers must inform employees requesting leave whether they are
eligible under FMLA. If they are, the notice must specify any additional
information required as well as the employees’ rights and responsibilities. If
they are not eligible, the employer must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as FMLA
protected and the amount of leave counted against the employee’s leave
entitlement. If the employer determines that the leave is not FMLA-protected,
the employer must notify the employee.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
Interfere with, restrain, or deny the exercise of any right provided under
FMLA;
Discharge or discriminate against any person for opposing any practice
made unlawful by FMLA or for involvement in any proceeding under or
relating to FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or may
bring a private lawsuit against the employer.
FMLA does not affect any Federal or State law prohibiting discriminating, or
supersede any State or local law or collective bargaining agreement which
provides greater family or medical leave rights.
2
Employee Rights and Responsibilities
Under the Family and Medical Leave Act
In addition to the Federal Family and Medical Leave At of 1993, EdCC provides leave in
accordance with the State of Washington regulations, and EdCC leave policies. This
documentation is a summary of the aforementioned leaves and is not all inclusive. For
more detailed information, please contact your HR representative. Please note: if you
are not eligible for FML, you may still be eligible for another type of leave under the
State of Washington Leave regulations, or within EdCC leave policies or practices. HRS
will monitor your leave request and make this determination.
3
Leave of Absence Request Notify your supervisor that you need to take leave for either your own health condition, that of your family
member, or for the birth/placement and care of a child
Family and Medical Leave Kit If taking leave for a possible qualifying event (i.e. medical leave, for domestic violence or military leave),
please fill out appropriate paperwork from the leave kit. You can make an appointment with your HR representative to discuss any other
issues.
Department Notification HR will keep in communication with you and your department regarding your leave request, return to work
information, limitations/restrictions, etc
The following should be considered when filling out the Family and Medical Leave Request forms.
Worker’s Compensation If leave is for a work-related injury or illness, call your HR representative.
Medical/Dental Do you have leave accruals to use or will you be on full Leave Without Pay (LWOP)? HR will provide information on how you
can use your leave to maintain your benefit. If you will be on full Leave Without Pay (LWOP), HR and Payroll will provide information regarding
premiums payments in order to keep benefits active.
Long Term Disability Insurance (LTD) If the leave is for your own medical condition, apply for Long Term Disability (LTD) benefits if you will
be off work longer than your waiting period and /or 90 days.
Your HR representative can provide you with claim forms and provide information/assistance regarding this benefit.
Shared Leave If leave is due to severe or life threatening circumstances, you may be eligible for Shared Leave. Contact your HR
representative. NOTE: Eligibility for Worker’s Compensation or LTD benefits will impact eligibility for shared leave.
Leave Request Form After reviewing the above topics, determine how you will use your leave and complete the Leave Request Form. Do not
hesitate to contact HR if you have questions.
Certification Form You will be responsible for providing the appropriate certification form to the appropriate medical provider or individual
and ensuring they provide the documentation to EdCC-HR. Important this information should not be provided to your supervisor or your
department, but submitted directly to HR.
Call in Requirements Plan with your supervisor and/or HR as to how often you should contact EdCC while you are on leave.
Other Important information of which to be aware:
Leave Without Pay (LWOP) Loss of Benefits
At the end of an FML period, or if you are on full LWOP for a non-FML event, you will lose eligibility for employer-paid benefits. Employees
maintain eligibility for employer-paid benefits if in paid status 8 or more hours in a month, but are still responsible for their portion of the
premiums, which 8 hours of pay may not cover. Contact HR for the criteria/limitations of how the 8 hours may be used. The Public Employee
Benefits Board will send a self-pay packet to the employee offering the option to continue benefit coverage on a self-pay basis.
If you lose employer-paid coverage, contact HR Benefits upon return to work to re-activate benefits.
Release to Return to Work
If you have been off work for your own medical condition, you may be required to submit to HR a Work Assessment Form completed by your
doctor prior to work. If the Work Assessment Form shows that you are unable to return to work on a full-time basis, or if you need temporary
modified duties, HR will coordinate a Return-to-Work Plan with your department.
Reasonable Accommodation (RA)
If your leave goes beyond the FML you may be able to have extended medical leave as a Reasonable Accommodation. Additionally, if the Work
Assessment Form shows you may have limitations/restrictions when released to work, a RA may also be pursued.
Life Insurance Premium Waiver
If you are or know you will be off work for more than 6 months for your own medical condition, contact HR Benefits for information regarding
the Life Insurance Premium Wavier. A life waiver allows an eligible employee to keep the life insurance coverage, but have the premiums
waived during the period of disability.
Disability Separation/Retirement
If circumstances dictate that you are unable to work, a disability separation or disability retirement may be pursued. HR Benefits personnel
will assist you in this matter.
Edmonds Community College
Leave of Absence Checklist for Employee’s Use
4
Edmonds Community College
Human Resources Representatives
Debbie Lau | dlau@email.edcc.edu | 425.640.1077
Assists employees whose last name begin with N-Z and all part-time faculty
Denise Olson | denise.olson@email.edcc.edu | 425.640.1069
Assists employees whose last name begin with A M and part-time hourly
Who is responsible for what?
Employee
Notifying supervisor of need for leave
Working with HR to fill out appropriate paperwork
Communicating with supervisor based on agreed upon “Call In
Requirements”
Providing the Work Assessment Form when requested and necessary for
return to work
Department
Referring request for medical leave to HR
Ensuring that payroll documents (PAF, Leave slips) are properly filled out,
and submitted on a timely basis while employee is on leave
Contacting HR with any questions about the leave or return to work
process
Human Resources
Counsel and advise employee and departments about medical leave and
return to work processes
Communicate with employing department regarding request and status
of leave
Assist with paperwork
Monitor process and paperwork for accuracy and timeliness
Coordinate efforts within HR and Payroll
EdmondsCommunityCollege
ExtendedLeaveRequestFormforanyofthefollowing:
FamilyMedicalLeave,FamilyCareLeave,DisabilityLeave,ParentalLeave,ServiceMember/VeteranCaregiverLeave,ExigencyLeave,
MilitarySpouseLeave,MilitaryLeave,DomesticViolenceLeave,andStateofEmergencyLeave
Employee:Pleasecomplete(consultHRforassistance)
Employee’sSignature Date
Employee: EmployeeID:
Department: CampusExt.:
Supervisor’sName: Supervisor’sExt:
EmployeeType:ClassifiedExemptFT/PTFaculty
HomeMailingAddress:
CityStateZip
HomePhoneNumber:
Personalemailaddress:
DoesyourspousealsoworkatEdCC?
Pleasecheckreason(s)forleaveofabsence:AdditionalCertificationDocumentationwillberequiredtosupportleaverequest.
Ownhealthcondition(notworkrelated)
Workrelatedcondition(contactBenefitServices)
Pregnancydisability(priortobirthofchild)
ApplyingforSharedLeave(SeeSharedLeaveapplication)
Carefornewborn/placedchild
Careforparent/spouse/childw/serioushealthcondition
ParentalLeave
LeaveforDomesticViolence,SexualAssaultorStalking
MilitaryLeave
ServiceMember/VeteranCaregiverLeave
ExigencyLeaveduetofamilymemberscalltoduty
MilitarySpouseLeave
StateofEmergencyLeave
Other
RequestStartDate: AnticipatedReturntoWorkDate:
Intermittentorreducedworkschedule(describe):
Pleasesubmitleaveslipforyouranticipatingtimeforyourextendedleave.Specifytheleaveyouwishtouse,thedates,onwhichto
applyitandthetotalleavehoursofeachtypeofleave.Forwardtosupervisorpriortothestartofyourleave.
TheFMLActpermitsanempl
oyertorequirethatyousubmit
atimely,complete,andsufficientmedicalcertificationtosupporta
requestforFML/Medicalleaveduetoyourownserioushealthconditionortocareforacoveredfamilymemberwithaserioushealth
condition.Failuretoprovideacompleteandsufficientmedicalcertificationmayresultinde
nialofyourFMLrequest.
Inrequestingle
ave,Iunderstandthatifmyrequestforleaveisincompleteorinsufficient,HRwillgiveme7daystoprovidethe
requestedinformation.IalsounderstandandreleaseappropriateHRprofessionals(i.e.officialHRpersonnelonlynotmysupervisor
ordepartmentmanagement)tocontac
tmyHCPtoauthenticate(confirmsignature)orclarifytheinformationprovided(understand
handwritingormeaningofresponse).IfIrefusetoprovidethisrelease,IunderstandthatEdCCcandenymyrequestforleave.
For HR use only:
Hasemployeeworkedforthestateforatleast1250hoursw/inthelast12
months&beenemployedatlast12months?
YesNo
IsthereasonforthisrequestanFMLAqualifyingevent? YesNo
IsthisleavedesignatedascoveredbyFMLA? YesNo
Datemedicalcertificationreceived
Datenotificationsent
Cctoemployee&supervisor
EMPLOYEE:Pleasefillinyournameandtakethisformtoyourlicensedhealthcareprovider(HCP).
EdCCEmployee:
HEALTHCAREPROVIDER:Pleasefilloutandreturn.
Pleaseaddressanyofthefollowingthatareapplicabletoyourpatient,whoisidentifiedaboveasthefamilymember.Several
questionsseekaresponseastothefrequencyordurationofacondition,treatment,etc.Beasspecificasyoucan;termssuchas
“lifetime,”“u
nkno
wn,”or“astolerated,”maynotbesufficienttodetermineFMLAcoverage.
Medicalfacts:Describerelevantmedicalfacts,ifany,relatedtothepatient’sconditionforwhichtheEdCCemployeeisseeking
leave(suchmedicalfactsmayincludesymptoms,diagnosis,ofanyregimentofcontinuingtreatmentsuchastheuseof
specializede
quipment.)

Pleaseid
entifyanyofthefollowingthatareapplicabletoyourpatient:
1.Inpatientcare(i.e.hospitalstay)includingperiodofincapacityofsubsequenttreatment.
If,yes,datesofadmission:
Continuingtreatmentbyahealthcareprovider(HCP),whichincludesanyoneormoreofthefollowing:
2. Incapacityofmorethan3daysplus,
TwoormoretreatmentsbyHCP;withthefirstvisitbeingwithin7daysoftheincapacity,andthesecondvisit
occurringwithin30daysoftheincapacityor
OnetreatmentbyHCPwithin7daysandcontinuingregimenundersupervisionofHCP.
3.Pre
gnanc
yanyperiodofincapacityduetopregnancyorprenatalcare.
4.IncapacityduetoChronicSeriousHealthCondition(SHC).AchronicSHCisonewhich:
A.Requiresperiodicvisitsortreatments(atleasttwiceperyear)byHCP
B.Continuesoveranextendedperiodoftime;i.e.physicalth
erapy
;and
C.Maycauseepisodicabsencesratherthancontinuedincapacity(asthma,diabetes,epilepsy,etc.)
5.PermanentorLong–TermConditions(Alzheimer’s,severestroke,terminalstagesofadisease,etc.)
6.MultipleTreatmentsforrestorativesurgeryorforaconditionthatwouldlikelyresultinaperiodofinca
pacityofmore
thanthreeday
sifnottreated.

Willtheemployeebemedicallyincapacitated(i.e.offworkfulltime)forasingleperiodoftime?NoYes
Ifso,begindateconditionpreventsemployeefromworkingonafulltimebasis:
Returntoworkdateonafulltimebasis,ifknown:
EdmondsCommunityCollege
MedicalLeaveCertificationFORFML,MedicalANDSharedLeave
FortheEmployee’sCondition
Parttimeorintermittentleave:
Willtheemployeeneedtoworkparttimeoronareducedworkbasis,orhavefollowupappointments?NoYes
Ifso,arethetreatmentsorthereducednumberofhoursofworkmedicallynecessary?NoYes
Estimatetreatmentscheduled,ifany,includingthedatesofanyscheduledappointmentsandthetimerequiredforeach
appointment,includinganyrecoveryperiod:
Estimatetheparttimeorreducedworkscheduletheemployeeneeds,ifany:
hour(s)perday;daysperweekfromthrough

Pleasenoteifthisaboveregimentisapplicabletoperforminganyworkfromhome,ifunabletomedicallyreleaseemployee
toreturntotheworksite?NoYes
(Employeewillneedtorequestandreceiveapprovalfromsupervisorpriortoworkingfromhome)
Willtheconditioncauseepisodicflareupsperiodicallypreventingtheemployeefromperforminghis/heressentialjob
functions?NoYes
Ifso,itismedicallynecessaryfortheemployeetobeabsentfromworkduringtheflareups?NoYes
Ifyes,explain:
Baseduponthepatient’smedicalhistoryandyourknowledgeoftheirmedicalcondition,estimatethefrequencyof
flareupsandthedurationofrelatedincapacitythatthepatientmayhaveoverthenext6months(e.g.1episodeevery3
monthslasting1‐2days):

Frequency:timesperweek(s)month(s)

Duration:
hour(s)orday(s)perepisode
Whenisnextscheduledappointmenttoreevaluate?
Istheemployeeunabletoperformanyofhis/herjobfunctionsduetothecondition,providedtheemployeeisabletoworkat
somecapacity,andbasedontheinformationeitherprovidedtoyoubytheemployerortheemployee’sowndesc
riptionofhis/
herjobfunctions?NoYes
Ifso,identifythejobfunctionstheemployeeisunabletoperform:
NameofLicensedHealthCareProviders: Specialty:

SignatureofLicensedHealthCareProviders:

Date:

Address:

Phonenumber:

Pleasereturnthisformto:
Employee/Patient

EdmondsCommunityCollegeHumanResourcesRepresentative
2000068
TH
AvenueWest|Lynnwood,Washington98036
Fax:425.640.1359|phone:425.640.1400
HeadStartFax:425.290.3693
FortheEmployee’sCondition,continued
EdmondsCommunityCollege
MedicalLeaveCertificationFORFML,MedicalANDSharedLeave
EMPLOYEE:Pleasefilloutthefollowinginformationandgivethisformandgivetoyourfamilymemberslicensedhealthcare
providertocomplete.
EdCCEmployee:
Nameoffamilymemberforwhomyouwillprovidemedicalcare:
Relationshipoffamilymembertoyou:
Iffamilymemberisyoursonordaughter,dateofbirth:
Describecareyouwillprovidetoyourfamilymemberandestimateleaveneededtoprovidecare:
EmployeeSignatureDate
HEALTHCAREPROVIDER:Pleasefilloutcompletely.
Pleaseaddressanyofthefollowingthatareapplicabletoyourpatient,whoisidentifiedaboveasthefamilymember.Severalquestions
seekaresponseastothefrequencyordurationofacondition,treatment,etc.Beasspecificasyoucan;termssuchas“lifetime,”
“unknown,”or“astolerated,”maynotbesufficienttodetermineFMLAcoverage.
Medicalfacts:Describerelevantmedicalfacts,ifany,relatedtothepatient’sconditionforwhichtheEdCCemployeeisseeking
leave(suchmedicalfactsmayincludesymptoms,diagnosis,ofanyregimentofcontinuingtreatmentsuchastheuseof
specializedequipment.)
Pleaseidentifyanyofthefollowingthatareapplicabletoyourpatie
nt:
1.I
npatientcare(i.e.hospitalstay)includingperiodofincapacityofsubsequenttreatment.
If,yes,datesofadmission:
Continuingtreatmentbyahealthcareprovider(HCP),whichincludesanyoneormoreofthefollowing:
2.Incapacityofmorethan3daysplus,
TwoormoretreatmentsbyHC
P;withthefirs
tvisitbeingwithin7daysoftheincapacity,andthesecondvisitoccurring
within30daysoftheincapacityor
OnetreatmentbyHCPwithin7daysandcontinuingregimenundersupervisionofHCP.
3.Pregnancyanyperiodofincapacityduetopregnancyofprenatalcar
e.
4.Inca
pacityduetoChronicSeriousHealthCondition(SHC).AchronicSHCisonewhich:
A.Requiresperiodicvisitsortreatments(atleasttwiceperyear)byHCP
B.Continuesoveranextendedperiodoftime;i.e.physicaltherapy;and
C.Maycauseepisodicabsencesratherthancontinuedin
capacity(asthma
,diabetes,epilepsy,etc.)
5.PermanentorLong–TermConditions(Alzheimer’s,severestroke,terminalstagesofadisease,etc.)
6.MultipleTreatmentsforrestorativesurgeryorforaconditionthatwouldlikelyresultinaperiodofincapacityofmorethan
threedaysifnottreated.
EdmondsCommunityCollege
MedicalLeaveCertificationFORFML,FamilyCareLeaveANDSharedLeave
ForFamilyMember’sCondition
EdmondsCommunityCollege
MedicalLeaveCertificationFORFML,FamilyCareLeaveANDSharedLeave
ForFamilyMember’sCondition,continued
AMOUNTOFCARENEEDED:Whenansweringthesequestionspleasekeepinmindthatyourpatient’sneedforcarebythe
employeeseekingleavemayincludeassistancewithbasicmedical,hygienic,nutritional,safetyortransportationneedsorthe
provisionofphysicalorpsychologicalcare.
Willthepatientbemedicallyincapacitatedforasingleperiodoftime,whichrequirethecare
oftheEdCCemployee?
NoYes

Ifso,begindateonconditionrequirescare:
Datewhencarewillnolongerbeneeded,ifknown:

Willthepatientneedcareonaparttimeorintermittentbasis?NoYes
Ifso,estimatetheparttimeorreducedworksche
duletheEdCCemplo
yeewillneedtoprovidecare,ifany:
hour(s)perday;daysperweekfromthrough

Explainthecareneededbythepatientwhysuchcareismedicallynecessary:




Willtheconditioncauseepisodicflareupsperiodicallyre
quiringthecareoftheEdCCemployeefo
ryourpatient?
NoYes

Ifso,baseduponthepatient’smedicalhistoryandyourknowledgeoftheirmedicalcondition,estimatethefrequencyof
flareupsandthedurationofrelatedincapacitythatthepatientmayhaveoverthenext6months(e.g.1episodeevery3
monthslasting12da
ys):

Frequency:
timesperweek(s)month(s)

Duration:hours(s)perday(s)perepisode

Explainthecareneededbythepatientandwhysuchcareismedicallynecessary.




Whenisthenextscheduledappointmenttoreevaluate?
NameofLi
censedHealthCareProviders: Specialty
:
SignatureofLicensedHealthCareProviders: Date:
Address: Phonenumber:
Pleasereturnthisformto:
Employee/Patient
EdmondsCommunityCollegeHumanResourcesRepresentative
2000068
TH
AvenueWest|Lynnwood,Washington98036
Fax:425.640.1359|phone:425.640.1400
HeadStartFax:425.290.3693
EdmondsCommunityCollege
ApplicationforSharedLeave
(Noteligibleforthosewhoareoffworkduetoworkrelatedinjuryorillness)
IfrequestforSharedLeaveisformedicalreasons,inordertoqualifyforShardLeaveanemployeemustbesufferingfrom,orhave
arelativeorhouseholdmembersufferingfromanextraordinaryorsevereillnessorinjury.Extraordinaryorsevereillnessorinjury
isdefinedasaseriousorextremeand/orlifethreateninginjuryorillness.
I
certifythatImeetalloftheserequirements.IhaveattachedtheMedicalLeaveCertificationformfromalicensedhealthcare
providerwhichdescribestheillness,injury,impairment,orphysicalormentalcondition.
Inadditiontoapplyingforsharedleave,IunderstandthatIalsomusthaveappliedfor:
FMLorMe
dicalLeave
LongTermDisability(LTD),ifapplicable
AnnouncementofSharedLeave(ifrequestisapproved)
IconsenttothepublicationofmynameinanEdCCAnnouncementnotifyingmyneedforsharedleavedonations.
Idoconsent
Idonotconsent
EmployeeSignature&Date:
EmployeeorEmployerRepresentative:Pleasecomplete
NameofEmployee: EmployeeSID:
Nameofpersonwithmedicalcondition: RelationshiptoEmployee:
TobecompletedbyHumanResources
Date‐Initials SharedLeaveApplicationReviewandCertification
CertificationofLeaveStatusviacopyoftime/leavereport
(attachtorequest).Employee’sleavebalancewillexpireon
OptionalLongTermDisabilityWaitingPeriodIfapproved,employeeisgrantedSharedLeavethrough
Employee’ssharedleaveisapproved.
Employee’srequestofsharedleaveisdeniedforthefollowingreasons:
NotasharedleavequalifyingeventhasenoughLvtosatisfyLTDwaitingperiodhasfile
daworkercompclaim
Sharedle
averequesthasbeenenteredontodatabase.SpreadsheetsenttoBUDGETforapproval.
HRRepresentativeSignature&Date:
Original‐SharedLeaveFile
Copies‐Recipient,Supervisor
Ownhealthcondition(notworkrelated)
Pregnancydisability(priortobirthofchild)
Careforrelative/householdmember
Pleasecheckreasonforrequestingsharedleave:
ReasonsforrequestingsharedleavewillalsobeprocessedaccordinglyforFamily
MedicalLeaveorotherfederal,stateorcollegeleaveprovision
.