See form attached 

Date:                                 

I,                                              , request family and medical leave for the following reason:  (check all that apply)

                         for the birth of my child;
                         for the placement of a child for adoption or foster care;
                         to care for my child who has a serious health condition;
                         to care for my parent who has a serious health condition;
                         to care for my spouse who has a serious health condition; or
                         because I am seriously ill and unable to perform the essential functions of my position.

I acknowledge my obligation to provide medical certification of my serious health condition or that of a family member in order to be eligible for family and medical leave within 15 days of the request for certification. 

I acknowledge receipt of information regarding my obligations under the family and medical leave policy of the school district.

I request that my family and medical leave begin on                                      and I request leave as follows: (check one)

                            continuous

I anticipate that I will be able to return to work on                 .

                            intermittent leave for the:

                                            birth of my child or adoption or foster care placement subject to agreement by the district
                                            serious health condition of myself, parent, or child when medically necessary

                          Details of the needed internmittent leave:

                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
 

                   I anticipate returning to work at my regular schedule on                                  .

                                            reduced work schedule for the:

                                            birth of my child or adoption or foster care placement subject to agreement by the school district

                                            serious health condition of myself, parent, or child when medically necessary

                          Details of the needed reduction in work schedule as follows:

                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________
                          _____________________________________________________________________________

                        I anticipate returning to work at my regular schedule on                                  .

I realize I may be moved to an alternative position during the period of the family and medical intermittent or reduced work schedule leave.  I also realize that with foreseeable intermittent or reduced work schedule leave, subject to the requirements of my health care provider, I may be required to schedule the leave to minimize interruptions to school district operations.

While on family and medical leave, I agree to pay my regular contributions to employer sponsored benefit plans.  My contributions shall be deducted from moneys owed me during the leave period.  If no monies are owed me, I shall reimburse the school district by personal check or cash for my contributions.  I understand that I may be dropped from the employer-sponsored benefit plans for failure to pay my contribution. 

I agree to reimburse the school district for any payment of my contributions with deductions from future monies owed to me or the school district may seek reimbursement of payments of my contributions in court. 

I acknowledge that the above information is true to the best of my knowledge.

Signed:  ________________________________________________________

Date:  _______________________________

1.  Employee's Name     ____________________________________________________

2.  Patient's Name  (if different from employee)  _________________________________

3.  The attached sheet describes what is meant by a "serious health condition" under the Family and Medical Leave Act.  Does the patient's condition, for which the
     employee is taking FMLA leave, qualify under any of the categories described?  If so, please check the applicable category.

     (1)                    (2)                   (3)                      (4)                      (5)                     (6)           

     or             None of the above

4.  Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories:

5.  a.  State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient's present
          incapacity, i.e. inability to work, attend school or perform other regular activities due to the serious health condition, treatment therefore, or recovery therefrom, if
          different):

      b.  Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment
           described in Item 6 below)?

           If yes, give the probable duration:

      c.  If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated and the likely duration and frequency of
           episodes of incapacity:

6.   a.  If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments:

If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number of and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:

      b.  If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the treatments:

      c.  If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g. prescription drugs,
           physical therapy requiring special equipment):

7.   a.  If medical leave is required for the employee's absence from work because of the employee's own condition (including absences due to pregnancy or a chronic
           condition), is the employee unable to perform work of any kind?

      b.  If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee's job (the employee or the employer
           should supply you with information about the essential job functions)?

           If yes, please list the essential functions the employee is unable to perform.

      c.  If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment?

8.   a.  If leave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal
           needs or safety, or for transportation?

      b.  If no, would the employee's presence to provide psychological comfort be beneficial to the patient or assist in the patient's recovery?

      c.  If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need:

__________________________________________________________      ____________________________________________________________
(Signature of Health Care Provider)                                                                   (Type of Practice)

__________________________________________________________      ____________________________________________________________
(Address)                                                                                                            (Telephone Number)

To be completed by the employee needing family leave to care for a family member.

State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule:

__________________________________________________________      ____________________________________________________________
(Employee Signature)                                                                                          (Date)

A serious health condition means an illness, injury impairment, or physical or mental condition that involves one of the following:

1. Hospital Care - In patient care (i.e. an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.

2. Absence Plus Treatment - A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves:
   a.  treatment two or more times by a health care provider, 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) under the orders of, or on referral by, a health care provider; or
   b.  treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.

3. Pregnancy - Any period of incapacity due to pregnancy or for prenatal care.

4. Chronic Conditions Requiring Treatments - A chronic condition which:
   a.  requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under direct supervision of a health care provider;
   b.  continues over an extended period of time (including recurring episodes of a single underlying condition); and
   c.  may cause episodic rather than a period of incapacity (e.g. asthma, diabetes, epilepsy, etc.).

5. Permanent/Long-term Conditions Requiring Supervision - A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by a health care provider.  Examples include Alzheimer's, a severe stroke, or the terminal stages of a disease.

6. Multiple Treatments (Non-chronic Conditions) - Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy) and kidney disease (dialysis).

A.      School district notice.

1. The school district will post the notice in Exhibit 409.3E1 regarding family and medical leave.

2. Information on the Family and Medical Leave Act and the board policy on family and medical leave, including leave provisions and employee obligations will be provided annually.  The information will be in the employee handbook.

3. When an employee requests family and medical leave, the school district will provide the employee with information listing the employee's obligations and requirements.  Such information will include:
   a.  a statement clarifying whether the leave qualifies as family and medical leave and will, therefore, be credited to the employee's annual 12-week entitlement;
   b.  a reminder that employees requesting family and medical leave for their serious health condition or for that of an immediate family member must furnish medical certification of the serious health condition and the consequences for failing to do so;
   c.  an explanation of the employee's right to substitute paid leave for family and medical leave including a description of when the school district requires substitution of paid leave and the conditions related to the substitution; and
   d.  a statement notifying employees that they must pay and must make arrangements for paying any premium or other payments to maintain health or other benefits.

B.       Eligible employees.  Employees are eligible for family and medical leave if three criteria are met.

1. The school district has more than 50 employees on the payroll at the time leave is requested;

2. The employee has worked for the school district for at least twelve months or 52 weeks (the months and weeks need not be consecutive); and

3. The employee has worked at least 1,250 hours within the previous year.  Full-time professional employees who are exempt from the wage and hour law may be presumed to have worked the minimum hour requirement.

C.     Employee requesting leave -- two types of leave.

1. Foreseeable family and medical leave
   a.  Definition - leave is foreseeable for the birth or placement of an adopted or foster child with the employee or for planned medical treatment.
   b.  Employee must give at least thirty days notice for foreseeable leave.  Failure to give the notice may result in the leave beginning thirty days after notice was received.
   c.  Employees must consult with the school district prior to scheduling planned medical treatment leave to minimize disruption to the school district.  The scheduling is subject to the approval of the health care provider.

2. Unforeseeable family and medical leave.
   a.  Definition - leave is unforeseeable in such situations as emergency medical treatment or premature birth.
   b.  Employee must give notice as soon as possible but no later than one to two work days after learning that leave will be necessary.
   c.  A spouse or family member may give the notice if the employee is unable to personally give notice.

D.    Eligible family and medical leave determination.  The school district may require the employee giving notice of the need for leave to provide reasonable documentation or a statement of family relationship.

1. Four purposes.
   a.  The birth of a son or daughter of the employee and in order to care for that son or daughter prior to the first anniversary of the child's birth;
   b.  The placement of a son or daughter with the employee for adoption or foster care and in order to care for that son or daughter prior to the first anniversary of the child's placement;
   c.  To care for the spouse, son, daughter or parent of the employee if the spouse, son, daughter or parent has a serious health condition; or
   d.  Employee's serious health condition that makes the employee unable to perform the essential functions of the employee's position.

2. Medical certification. 
   a.  When required:
        (1)  Employees shall be required to present medical certification of the employee's serious health condition and inability to perform the essential
              functions of the job.
        (2)  Employees shall be required to present medical certification of the family member's serious health condition and that it is medically necessary for
               the employee to take leave to care for the family member.
   b.  Employee's medical certification responsibilities:
        (1)  The employee must obtain the certification from the health care provider who is treating the individual with the serious health condition.
        (2)  The school district may require the employee to obtain a second certification by a health care provider chosen by and paid for by the school district
               if the school district has reason to doubt the validity of the certification an employee submits.  The second health care provider cannot, however, be
               employed by the school district on a regular basis.
        (3)  If the second health care provider disagrees with the first health care provider, then the school district may require a third health care provider to
              certify the serious health condition.  This health care provider must be mutually agreed upon by the employee and the school district and paid for by
              the school district.  This certification or lack of certification is binding upon both the employee and the school district
   c.  Medical certification will be required fifteen days after family and medical leave begins unless it is impracticable to do so.  The school district may request recertification every thirty days.  Recertification must be submitted within fifteen days of the school district's request.

Family and medical leave requested for the serious health condition of the employee or to care for a family member with a serious health condition which is not supported by medical certification will be denied until such certification is provided.

E.     Entitlement.

1. Employees are entitled to twelve weeks unpaid family and medical leave per year. 

2. Year is defined as fiscal year

3. If insufficient leave is available, the school district may:
   a.  Deny the leave if entitlement is exhausted
   b.  Award leave available

F.     Type of Leave Requested.

1. Continuous - employee will not report to work for set number of days or weeks.

2. Intermittent - employee requests family and medical leave for separate periods of time.
   a.  Intermittent leave is available for:
        (1)  Birth, adoption or foster care placement of child only with the school district's agreement.
        (2)  Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district's agreement.
   b.  In the case of foreseeable intermittent leave, the employee must schedule the leave to minimize disruption to the school district operation.
   c.  During the period of foreseeable intermittent leave, the school district may move the employee to an alternative position with equivalent pay and
        benefits. 

3. Reduced work schedule - employee requests a reduction in the employee's regular work schedule.
   a.  Reduced work schedule family and medical leave is available for:
        (1)  Birth, adoption or foster care placement and subject to the school district's agreement.
        (2)  Serious health condition of the employee, spouse, parent, or child when medically necessary without the school district's agreement.
   b.  In the case of foreseeable reduced work schedule leave, the employee must schedule the leave to minimize disruption to the school district operation.
   c.  During the period of foreseeable reduced work schedule leave, the school district may move the employee to an alternative position with equivalent pay
        and benefits. 

G.    Employee responsibilities while on family and medical leave.

1. Employee must continue to pay health care benefit contributions or other benefit contributions regularly paid by the employee unless employee elects not to continue the benefits.

2. The employee contribution payments will be deducted from any money owed to the employee or the employee will reimburse the school district at a time set by the superintendent.

3. An employee who fails to make the health care contribution payments within thirty days after they are due will be notified that their coverage may be canceled if payment is not received within an additional 15 days.

4. An employee may be asked to re-certify the medical necessity of family and medical leave for the serious medical condition of an employee or family member once every thirty days and return the certification within fifteen days of the request. 

5. The employee must notify the school district of the employee's intent to return to work at least once each month during their leave and at least two weeks prior to the conclusion of the family and medical leave.

6. If an employee intends not to return to work, the employee must immediately notify the school district, in writing, of the employee's intent not to return.  The school district will cease benefits upon receipt of this notification.

H.   Use of paid leave for family and medical leave.  An employee may substitute unpaid family and medical leave with appropriate paid leave available to the employee under board policy, individual contracts or the collective bargaining agreement.  Paid leave includes, but is not limited to, sick leave, family illness leave, vacation, personal leave, bereavement leave and professional leave.  When the school district determines that paid leave is being taken for an FMLA reason, the school district will notify the employee within two business days that the paid leave will be counted as FMLA leave.

Common law marriage-according to Iowa law, common law marriages exist when there is a present intent by the two parties to be married, continuous cohabitation, and a public declaration that the parties are husband and wife.  There is no time factor that needs to be met in order for there to be a common law marriage.

Continuing treatment-a serious health condition involving continuing treatment by a health care provider includes any one or more of the following:

• A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from) of more than three consecutive calendar days and any subsequent treatment or period of incapacity relating to the same condition that also involves:
  --       treatment two or more times by a health care provider, 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) under orders of, or in referral by, a health care provider; or
  --       treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of a the health
           care provider.
•     Any period of incapacity due to pregnancy or for prenatal care.
•     Any period of incapacity or treatment for such incapacity due to a chronic serious health condition.  A chronic serious health condition is one which:
  --       requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care
           provider;
  --       Continues over an extended period of time (including recurring episodes of a single underlying condition); and
  --       May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
• Any period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider.  Examples include Alzheimer's, a severe stroke or the terminal stages of a disease.
• Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Eligible Employee-the district has more than 50 employees on the payroll at the time leave is requested.  The employee has worked for the district for at least twelve months and has worked at least 1250 hours within the previous year.

Essential Functions of the Job-those functions which are fundamental to the performance of the job.  It does not include marginal functions.

Employment benefits-all benefits provided or made available to employees by an employer, including group life insurance, health insurance, disability insurance, sick leave, annual leave, educational benefits, and pensions, regardless of whether such benefits are provided by a practice or written policy of an employer or through an "employee benefit plan."

Family Member-individuals who meet the definition of son, daughter, spouse or parent.

Group health plan-any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer's employees, former employees, or the families of such employees or former employees.

Health care provider-

• A doctor of medicine or osteopathy who is authorized to practice medicine or surgery by the state in which the doctor practices; or
• Podiatrists, dentists, clinical psychologists, optometrists, and chiropractors (limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X ray to exist) authorized to practice in the state and performing within the scope of their practice as defined under state law; and
• Nurse practitioners and nurse-midwives, and clinical social workers who are authorized to practice under state law and who are performing within the scope of their practice as defined under state law; and
• Christian Science practitioners listed with the First Church of Christ Scientist in Boston, Massachusetts;
• Any health care provider from whom an employer or a group health plan's benefits manager will accept certification of the existence of a serious health condition to substantiate a claim for benefits;
• A health care provider as defined above who practices in a country other than the United States who is licensed to practice in accordance with the laws and regulations of that country.

In loco parentis-individuals who had or have day-to-day responsibilities for the care and financial support of a child not their biological child or who had the responsibility for an employee when the employee was a child.

Incapable of self-care-that the individual requires active assistance or supervision to provide daily self-care in several of the "activities of daily living" or "ADLs."  Activities of daily living include adaptive activities such as caring appropriately for one's grooming and hygiene, bathing, dressing, eating, cooking, cleaning, shopping, taking public transportation, paying bills, maintaining a residence, using telephones and directories, using a post office, etc.

Instructional employee-an employee employed principally in an instructional capacity by an educational agency or school whose principal function is to teach and instruct students in a class, a small group, or an individual setting, and includes athletic coaches, driving instructors, and special education assistants such as signers for the hearing impaired.  The term does not include teacher assistants or aides who do not have as their principal function actual teaching or instructing, nor auxiliary personnel such as counselors, psychologists, curriculum specialists, cafeteria workers, maintenance workers, bus drivers, or other primarily noninstructional employees.

Intermittent leave-leave taken in separate periods of time due to a single illness or injury, rather than for one continuous period of time, and may include leave or periods from an hour or more to several weeks.

Medically Necessary-certification for medical necessity is the same as certification for serious health condition.

"Needed to Care For"-the medical certification that an employee is "needed to care for" a family member encompasses both physical and psychological care.  For example, where, because of a serious health condition, the family member is unable to care for his or her own basic medical, hygienic or nutritional needs or safety or is unable to transport himself or herself to medical treatment.  It also includes situations where the employee may be needed to fill in for others who are caring for the family member or to make arrangements for changes in care.

Parent-a biological parent or an individual who stands in loco parentis to a child or stood in loco parentis to an employee when the employee was a child.  Parent does not include parent-in-law.

Physical or mental disability-a physical or mental impairment that substantially limits one or more of the major life activities of an individual.

Reduced leave schedule-a leave schedule that reduces the usual number of hours per workweek, or hours per workday, of an employee.

Serious health condition

• An illness, injury, impairment, or physical or mental condition that involves:
• Inpatient care (i.e. an overnight stay) in a hospital, hospice or residential medical care facility including any period of incapacity (for purposes of this section, defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from), or any subsequent treatment in connection with such inpatient care; or
  --       Continuing treatment by a health care provider.  A serious health condition involving continuing treatment by a health care provider includes:
            --       A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment
                     for or recovery from) of more than three consecutive calendar days, including any subsequent treatment or period of incapacity relating to the
                     same condition, that also involves:
            --       Treatment two or more times by a health care provider, 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) under orders or, or on referral by, a health care provider; or
            --       Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the
                      health care provider.
  --       Any period of incapacity due to pregnancy or for prenatal care.
  --       Any period of incapacity or treatment for such incapacity due to a chronic serious health condition.  A chronic serious health condition is one which:
  --       Requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care
            provider;
           --       Continues over an extended period of time (including recurring episodes of s single underlying condition); and
           --       May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
  --       A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member
           must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider.  Examples include Alzheimer's a
           severe stroke or the terminal stages of a disease.
  --       Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care
           services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that
           would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as
           cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).
• Treatment for purposes of this definition includes, but is not limited to, examinations to determine if a serious health condition exists and evaluation of the condition.  Treatment does not include routine physical examinations, eye examinations or dental examinations.  Under this definition, a regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition (e.g., oxygen).  A regimen of continuing treatment that includes the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed rest, drinking fluids, exercise and other similar activities that can be initiated without a visit to a health care provider, is not, by itself, sufficient to constitute a regimen of continuing treatment for purposes of FMLA leave.
• Conditions for which cosmetic treatments are administered (such as most treatments for acne or plastic surgery) are not "serious health conditions" unless inpatient hospital care is required or unless complications develop.  Ordinarily, unless complications arise, the common cold, the flu, ear aches, upset stomach, ulcers, headaches other than migraine, routine dental or orthodontia problems, periodontal disease, etc., are examples of conditions that do not meet the definition of a serious health condition and do not qualify for FMLA leave.  Restorative dental or plastic surgery after an injury or removal of cancerous growths, are serious health conditions provided all the other conditions of this regulation are met.  Mental illness resulting from stress or allergies may be serious health conditions, but only if all the conditions of this section are met.
• Substance abuse may be a serious health condition if the conditions of this section are met.  However, FMLA leave may only be taken for treatment for substance abuse by a health care provider or by a provider of health care on referral by a health care provider.  On the other hand, absence because of the employee's use of the substance, rather than for treatment, does not qualify for FMLA leave.
• Absence attributable to incapacity under this definition qualify for FMLA leave even though the employee or the immediate family member does not receive treatment from a health care provider during the absence, and even if the absence does not last more than three days.  For example, an employee with asthma may be unable to report for work due to the onset of an asthma attack or because the employee's health care provider has advised the employee to stay home when the pollen count exceeds a certain level.  An employee who is pregnant may be unable to report to work because of severe morning sickness.

Son or daughter-a biological child, adopted child, foster child, stepchild, legal ward, or a child of a person standing in loco parentis.  The child must be under age 18 or, if over 18, incapable of self-care because of a mental or physical disability.

Spouse-a husband or wife recognized by Iowa law including common law marriages.