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Request for FMLA/OFLA Leave
INSTRUCTIONS FOR EMPLOYEES: See page 2 of this form for explanation of qualifications for Federal Family and Medical Leave
Act (FMLA) or Oregon Family Medical Leave (OFLA). If you have questions, call Human Resources for assistance (503-385-4706). This
leave request must be completed if leave is used under the FMLA/OFLA. All leave qualifying as FMLA and/or OFLA will be counted as such.
Sign and submit all copies of this completed leave request to Human Resources.
Name: _________________________________________
Department: ____________________________________
Supervisor: _____________________________________
Contact #: ______________________________
Job Title: _______________________________
Date of Hire: ____________________________
Work Schedule:
Monday Tuesday Wednesday Thursday Friday Hours per Day: _____________________
Full time Part time FTE: __________________________
Begin Leave: ______________________________ End Leave: ____________________________________
Continuous ORIntermittent
Have you taken Family leave in the past 12 months?  Yes   No
If yes, previous date _____________________________
Please indicate the reason for leave: (See page 2 for qualifying events)
My own serious health condition
(employee must turn in the “WESD Release to Work Authorization”
form prior to returning to work)
Family member’s serious health condition,
please identify family member ______________________
Sick child
Parental leave
Confidentiality: Any disclosure of medical information will be kept in a confidential file and will be used only for determining eligibility for
OFLA/FMLA and tracking of leave.
FMLA/OFLA leave requests must be received in HR within 30 days of scheduled leave or if unexpected leave is
requested, as soon as possible.
I understand that [the ESD requires me to use any accrued sick leave, vacation, personal leave days or other paid time established by Board
policy(ies) and/or collective bargaining agreement in the order specified by the ESD, and before taking leave without pay, for the family and
medical leave period.] [I am required to use any accrued paid leave, including personal and sick leave or accrued vacation leave before taking
family and medical leave without pay. I may select the order in which the paid leave is used for the family and medical leave period.]
If my request for a leave is approved, it is my understanding that without an authorized extension when the need for an extension could be
anticipated, I must report to duty on the first workday following the date my leave is scheduled to end. I understand that failure to do so will
constitute unequivocal notice of my intent not to return to work and the ESD may terminate my employment. A fitness-for-duty statement may
be required.
I authorize the ESD to deduct from my paychecks any employee contributions for health insurance premiums, life insurance or long-term
disability insurance which remain unpaid after my leave, consistent with state and/or federal law. I have been provided a copy of the ESD’s
family and medical leave policy and a copy of my rights and responsibilities under the Family Medical Leave Act leave request form.
EMPLOYEE SIGNATURE: ___________________________________________ Date: _________________
1. Ensure all applicable parts of the form are completed. Questions? Call 503-385-4706
2. Fax signed form to Human Resources IMMEDIATELY at 503-363-5787
Leave Request: FMLA OFLA Both
Employee Eligible: Yes No
Original Request Revision Cancellation
Receipt by HR: _____________
Pregnancy, please identify due date:
Family member injured while on active military duty
Qualifying exigency related to family member’s active
duty military call-up
Bereavement leave for death of a family member
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FMLA: Employees who worked for a total of at least 12 months (not necessarily consecutive) AND
worked at least 1250 hours during the 12 month period.
OFLA: Employees who worked for a period of 180 calendar days immediately preceding the date
leave begins, AND worked an average of 25 hours per week during the 180 day period (unless
parental leave).
Exception 1: For parental leave, workers are eligible after being employed for 180
calendar days, without regard to the number of hours worked.
Exception 2: For Oregon Military Family Leave, eligible workers must work for an
employer an average of at least 20 hours per week, without regard to the
number of days worked.
Pregnancy Leave - taken prior to birth of child.
Parental Leave - Adoption of a child up to age 18 (or older than 18 if incapable of self-care) or the
newly placed foster child. Care of a new born child (birth of a child).
Family Member Leave:
Care of a spouse, parent, child of the employee (biological, adopted, foster or step child, a
legal ward, or child of the employee standing in loco parentis), custodial parent, noncustodial
parent, biological parent, adoptive parent, stepparent or foster parent, individual who was in
loco parentis to the employee when the employee was a child, same-gender domestic
partner, child of same-gender domestic partner, grandparent, grandchild, parent-in-law, or
parent of the employee’s same-gender domestic partner.
To care for a sick child with an illness or injury that is not a serious health condition.
Your own serious health condition (see item B1, B2, or B3 below).
Family Member injured while on active military duty.
Qualifying exigency related to family member’s active duty military call-up.
Bereavement Leave for death of a family member.
* see above under “Family Member Leave” for definition
1. An illness, injury, impairment or physical or mental condition that involves :
Inpatient care in a hospital, hospice or residential medical care facility (i.e. an overnight stay);
including any period of incapacity (defined as an inability to work, attend school or perform other
regular daily activities), or any subsequent treatment in connection with such inpatient care;
2. Continuing treatment by a health care provider that includes one OR more of the following:
A period of incapacity of more than three consecutive calendar days, and any subsequent treatment
or period of incapacity relating to the same condition, that also involves (i) treatment two or more
times by a health care provider, or by a nurse or physician’s assistant under direct supervision of a
health care provider, or by a provider of health care services (e.g. physical therapist) on referral by a
health care provider; or (ii) treatment by a health care provider on at least one occasion which results
in a regiment of continuing treatment.
A period of incapacity due to pregnancy, or for prenatal care.
A period of incapacity or treatment for a “chronic” serious health condition which requires periodic
visits for treatment by a health care provider continues over an extended period and may cause
episodic rather than continuing period of incapacity (e.g., asthma, diabetes, epilepsy).
A period of incapacity which is permanent or long-term due to a condition for which treatment is not
effective (e.g. Alzheimer’s disease, severe stroke, terminal cancer).
A period of absence to receive multiple treatments for an injury or condition which would result in
incapacitation of more than three days if not treated (e.g. chemotherapy or radiation for cancer,
physical therapy for severe arthritis, or dialysis for kidney disease).
Note: Short-term conditions requiring only brief treatment and recovery are not “serious health
conditions” (e.g. common cold, flu, ear aches, upset stomach, minor ulcers, headaches other than
migraines, routine dental or orthodontia problems and periodontal disease).
3. An illness, disease or condition that in the medical judgment of the treating health care provider poses an
imminent danger of death, is terminal in prognosis with a reasonable possibility of death in the near future, or
requires constant care.