Fillable REQUEST FOR FAMILY AND MEDICAL LEAVE (Birdville Schools)

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REQUEST FOR FAMILY AND MEDICAL LEAVE (Birdville Schools)

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Human Resources
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Request for Family or Medical Leave (FML) must be made at least 30 days (if possible) prior to the date the
requested leave is to begin. Any leave approved will require the use of all applicable sick leave and vacation
time.
Employee Name: Date:
Employee ID #: Hire Date: Contact #:
Position/Assignment: Campus/Department:
Personal Email Address:
(other than Birdville email address)
I request family or medical leave for one or more of the following reasons:
Birth or adoption of child
Expected date of birth:
Date leave to start:
Expected date to return:
In order to care for spouse, child or parent who has a serious health condition
Date leave to start:
Expected date to return:
Serious health condition that prevents me from performing my job
Explain:
Date leave to start:
Expected date to return:
PLEASE ATTACH MEDICAL CERTIFICATION FROM HEALTH CARE PROVIDER FOR ANY
REQUESTED LEAVE FOR A SERIOUS HEALTH CONDITION OR BIRTH OF A CHILD.
1 FML Request 01.25.2018
Form R-98
Birdville
Independent
School
District
Instructions: Complete this form, obtain the signature of your principal/supervisor
and submit entire form to the BISD Human Resources Department.
Birdville Independent School District
Human Resources
2
Form R-98
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Have you taken a family or medical leave in the past 12 months? Yes No
If yes, how many workdays did you miss due to FMLA?
Have you had any absences due to the condition for which you are requesting the leave?
Yes No
If yes, please list the dates
Are you currently covered under the Birdville ISD health insurance program? Yes No
If yes, the premium payment will be deducted from your payroll check as usual. If your wages become insufficient to cover the
premium, you must submit a personal check to BISD to cover the insurance cost.
I UNDERS
TAND AND AGREE TO THE FOLLOWING PROVISIONS:
• I have worked for my employer at least one year and at least 1,250 hours in the previous months.
• All days not covered by sick leave or vacation will be unpaid.
• After 12 weeks of leave, if I am unable to return to work, I must contact my supervisor and the
BISD Human Resources Department to report my status.
• The position of non-contracted employee is not guaranteed 12 weeks.
• If I do not return to work after the leave, the Birdville ISD will recover the cost of any benefits
incurred during the time of the leave.
• If the requested leave is due to my own serious health condition, I must submit medical
certification of my ability to resume work.
Employ
ee Signature: Date:
LEAVE APPROVALS:
Princ
ipal: Date:
Manager/Supervisor: Date:
Human Resources: Date:
PAYROLL INSTRUCTIONS:
With pa
y from: to: Total # work days:
Without pay from: to: Total # work days:
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
(FAMILY AND MEDICAL LEAVE ACT)
Copyright 12/1
5/2008 Texas Association of School Boards. All rights reserved.
OMB Control Number: 1215-0181
Form WH-380-E November 2008
Section I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to
submit a medical certification issued by the employee’s health care provider. Please complete Section I before giving
this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask
the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306–825.308.
Employers must generally maintain records and documents relating to medication certifications, re-certifications, or
medical histories of employees created for FMLA purposes as confidential medical records in separate files/records
from the usual personnel files and in accordance with 29 C.F.R. § 1630.14 (c) (1), if the Americans with Disabilities
Act applies.
Employer Name and Contact:
Birdville Independent School District
Melissa Sims / Human Resources
( 817) 547-5764 office / (817) 547-5536 fax
Employee’s Job Title: Regular Work Schedule: ________________
Employee’s Essential Job Functions: ________________________________________________________________
_____________________________________________________________________________________________
Job descripti
on attached
Section II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical
provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical
certification to support a request for FMLA leave due to your own serious health condition. If requested by your
employer, your response is required to obtain or retain the benefit of FMLA protections, 29 U.S.C. §§ 2613, 2614
(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request,
29 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form, 29 C.F.R.
§825.305(b).
Your Name:_______________________________ ______________________ _____________________________
First Middle Last
Section III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA.
Answer, fully and completely, all applicable parts. Several questions seek a response as to frequency or duration of a
condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience,
and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate”
may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is
seeking leave. Please be sure to sign the form on the last page.
Provider’s Name and Business Address: _____________________________________________________________
_____________________________________________________________________________________________
Type of Practice / Medical Specialty: _______________________________________________________________
Telephone:
( ) Fax: ( )
fml_cert_employee
12.06.2017
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
(FAMILY AND MEDICAL LEAVE ACT)
Cop
yright 12/15/2008 Texas Association of School Boards. All rights reserved.
Part A: Medical Facts
1. Approximate date condition commenced: __________________________________________________________
Pr
obable duration of condition: ________________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes No If yes, provide dates of admission: _________________________________________________
Da
te(s) you treated the patient for condition: ______________________________________________________
Will th
e patient need to have treatment visits at least twice per year due to the condition? Yes No
Was medication, other than over-the-counter medication, prescribed? Yes No
Was
the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
Yes No If yes, state the nature of such treatments and expected durations of treatment:
__________________________________________________________________________________________
2. Is the medical condition pregnancy? Yes No If yes, expected delivery date:
3. Us
e the information provided by the employer in Section I to answer this question. If the employer fails to provide
a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s
own description of his/her job functions.
Is
the employee unable to perform any of his/her job functions due to the condition? Yes No
If s
o, identify the job functions the employee is unable to perform: _____________________________________
__________________________________________________________________________________________
4. Des
cribe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of
specialized equipment):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
(FAMILY AND MEDICAL LEAVE ACT)
C
opyright 12/15/2008 Texas Association of School Boards. All rights reserved.
Part B: AMOUNT OF LEAVE NEEDED
5. W
ill the employee be incapacitated for a single continuous period of time due to his/her medical condition,
including any time for treatment and recovery? Yes No
I
f so, estimate the beginning and ending dates for the period of incapacity: _______________________________
__________________________________________________________________________________________
6. W
ill the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedul
e
b
ecause of the employee’s medical condition? Yes No
I
f so, are the treatments or the reduced number of hours of work medically necessary? Yes No
E
stimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment, including any recovery period: __________________________________________________
__________________________________________________________________________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
hour(s) per day; days per week from through ___________
7. W
ill the condition cause episodic flare-ups periodically preventing the employee from performing his/her j
ob
f
unctions? Yes No
I
s it medically necessary for the employee to be absent from work during the flare-ups? Yes No
If yes, explain: _____________________________________________________________________________
__________________________________________________________________________________________
B
ased upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of
flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode
every 3 months lasting 1–2 days).
Frequency: times per week(s) month(s)
Duration: hours or day(s) per episode
ADDITIONAL INFORMATION: Identify Question Number with Your Additional Answer:
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
(FAMILY AND MEDICAL LEAVE ACT)
C
opyright 12/15/2008 Texas Association of School Boards. All rights reserved.
Signature of Health Care Provider Date
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, 29
U.S.C. § 2616, 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless
it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average
of 20 minutes for respondents to complete this collection of information, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. If you have any comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, send them to the
Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW
Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR;
RETURN TO THE PATIENT.
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REQUEST FOR FAMILY AND MEDICAL LEAVE (Birdville Schools)

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Completed 29 September 2020

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