GCBDA/GDBDA-AR(2) – Employee Request for OFLA Leave

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Where the need for the leave may be anticipated, written request for OFLA leave must be made, if practical, at least 30 days prior to the date the requested leave is to begin. Failure to provide timely notice could result in the district reducing the available OFLA leave by up to three weeks.

Name Effective Date of the Leave

Department Title

Status: □ Full-time □ Part-time □ Temporary Hire Date Length of Service

I request OFLA leave for one or more of the following reasons:¹

1. ☐ Because of the birth of my child and in order to care for him or her.

Expected date of birth Actual date of birth Leave to start Expected return date

2. ☐ Because of the placement of a child with me for adoption or foster care.

Age of child Date of placement Leave to start Expected return date

3. ☐ In order to care for a family member² with a serious health condition.
4. ☐ Leave to start Expected return date

Please check one: □ spouse³ □ child (including the biological, grandchild, adopted, foster child or stepchild of an employee or a child with whom the employee is or was in a relationship of “in loco parentis”) □ parent (biological parent of an employee or an individual who stood “in loco parentis” to an employee when the employee was a child), □ custodial

parent □ noncustodial parent □ biological parent □ adoptive parent □ stepparent or foster parent □ grandparent □ parent-in-law or parent of the employee’s registered domestic partner

• □ grandchild

Please state name and address of relation:

Name Address

Describe serious health condition

5. ☐ A sick child leave due to the closure of a child’s school or child care provider.
6. ☐ For a serious health condition which prevents me from performing my job functions.

Describe

Leave to start Expected return date

Regarding 3 or 4 above, request intermittent (reduced workday hours) or reduced leave (fewer workdays each workweek) schedule or alternate duty (if applicable, subject to employer’s approval). Please describe schedule of when you anticipate you will be unavailable to work:

7. ☐ In order to care for a child with a condition requiring home care which does not meet the definition of serious health condition and is not life threatening or terminal. □ Yes □ No

Have you taken OFLA leave in the past 12 months? □ Yes □ No If yes, how many workdays?

8. ☐ Leave for the spouse of a military personnel when they have been notified of an impending call to active duty, ordered to active duty, or has been deployed or is on leave from deployment.
9. ☐ The death of a family member.⁴

I understand that the district requires me to use any available accrued sick leave, vacation, personal leave days or other available paid time established by Board policy(ies) and/or collective bargaining agreement in the order specified by the district and before taking leave without pay, for the 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 district may terminate my employment. (A fitness-for-duty certification may be required.)

I authorize the district 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 law.

I have been provided a copy of the district’s family and medical leave policy with this OFLA leave request form.

Signature of Employee: Date:

¹ A physician’s certification may be required to support a request for OFLA leave. In addition, a fitness-for-duty certification may be required before reinstatement following the leave.

² “Family member” means the spouse, 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, grandparent, grandchild, parents-in-law or the parents of the employee’s registered domestic partner.

³ “Spouse” means individuals in a marriage, including “common law” marriage, same-sex marriage or same sex individuals with a Certificate of Registered Domestic Partnership.

⁴ Must be completed within 60 days of the date on which the eligible employee receives notice of the death of the family member.