Fillable TOWN OF LOS GATOS EMPLOYEE REQUEST FOR FAMILY (Town of Los Gatos)

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TOWN OF LOS GATOS EMPLOYEE REQUEST FOR FAMILY (Town of Los Gatos)

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TOWN OF LOS GATOS
EMPLOYEE REQUEST FOR FAMILY OR MEDICAL LEAVE
Human Resources Department
Employee Name: Date:
Employee Number: Department:
Reason for Leave: I am requesting this Family/Medical Leave for:
Birth /Adoption / Foster Placement (Circle one)
My Own Serious Health Condition (Medical Certification Required)
The Serious Health Condition of Family Member (Medical Certification Required)
Child Spouse Parent
Exigent circumstances arising from Family Member called to active military duty (Medical Certification
Required)
To care for a Family Member injured on active military duty (Medical Certification Required)
Duration of Family / Medical Leave
Expected date of birth / adoption / or placement for foster care: __________________
Leave Start Date __________________ Expected Return To Work Date __________________
I understand the following:
1. The leave indicated above will be counted against my entitlement under the Family and Medical Leave Act
(FMLA). This leave is 12-weeks in any given 12-month period, except for the special one-time leave of up to
26 weeks to care for a family member injured while on active military duty.
2. Upon return to work; I am entitled to be restored to the same or an equivalent position;
3. If my leave is due to my serious health condition, that of a family member, or to care for a family member
injured while on active military duty, I will be required to provide a medical certification, or risk having my
leave request denied;
4. I may choose to use any paid leave for which I am eligible concurrent with my FMLA Leave;
5. If my leave is for my own serious health condition, I may be required to provide a fitness-for-duty
certificate upon my return;
_______________________ ________________________
Signature of Employee Date
_______________________ ___________________________ _____________________
Signature of Supervisor Signature of Department Director Date
Please return one copy of this form to the Human Resources Department, and retain the other for your records.
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TOWN OF LOS GATOS EMPLOYEE REQUEST FOR FAMILY (Town of Los Gatos)

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Completed 3 August 2020

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