Employee Information Request for Family or Medical Leave  (FMLA)
This information will be used to send you appropriate paperwork. PLEASE NOTE: Completing this form does not guarantee FMLA eligibility or approval.


Board Policy:  
Certificated Staff-  Policy 3430.01
Classified Staff- Policy 4430.01
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Email *
FMLA: Employee Request for Family or Medical Leave  
Request form for FMLA information.

An employee seeking (or confirming) a family or medical leave must check all applicable boxes, complete, and submit at least thirty (30) days prior to the desired start date of the leave (if practicable because the leave is foreseeable) or as soon as practicable if the leave has already begun or was not foreseeable. Leave requests for any qualifying exigency for military family leave must be submitted as soon as practicable.
Last Name *
First Name *
Position *
Phone Number *
Assigned Building *
Please select all that apply.
Required
Who is leave needed for: *
Required
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