"Request for Family/Medical Leave of Absence" - City of St. Louis, Missouri

Request for Family/Medical Leave of Absence is a legal document that was released by the Personnel Department - City of St. Louis, Missouri - a government authority operating within Missouri. The form may be used strictly within City of St. Louis.

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  • Released on December 1, 2009;
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REQUEST FOR FAMILY/MEDICAL LEAVE OF ABSENCE
This form is to be completed by the EMPLOYEE requesting a paid or unpaid
leave of absence under provisions of the federal "Family and Medical Leave
Act of 1993" and City of St. Louis Administrative Regulation No. 133.
This
form should be completed and submitted to the Appointing Authority at least
thirty (30) days in advance of the beginning of such leave, except in those
cases where the nature of the medical/family emergency precludes such advance
notice.
1.
EMPLOYEE NAME: _________________________________________________________
2.
JOB TITLE: _____________________________________________________________
3.
DEPARTMENT:
4. DIVISION/SECTION:____________________
5.
REQUESTED LEAVE PERIOD:
From
To _____________________
6.
PAID LEAVE REQUESTED:
_________________________________________________
7.
I request Family/Medical Leave for the following reason:
For a personal serious health condition which renders me unable to
perform the functions of my job
For the anticipated birth and care of a newborn son/daughter
For the placement and/or care of a newly adopted child or foster
child
To care for the following qualifying relative with a serious health
condition (check one):
Legal spouse
Parent (includes natural or adoptive parent, stepparent, legal
guardian; does not include in-laws)
Person with "in loco parentis" status to the employee when the
employee was a child
Son or Daughter (includes natural, adoptive or foster child, or
stepchild, who is either under 18, or age 18 or older and
incapable of self-care because of a mental or physical
disability)
Child for whom employee has status as "in loco parentis"
8.
If the requested leave is for the birth or adoption of a child, or the
placement of a foster child, does your spouse also work for the City of
St. Louis?
Yes
No
9.
If the request for leave involves a "serious medical condition" of
either the employee or a qualifying relative, complete the following:
A.
If the employee will be providing care for a qualifying relative,
please print the full name of the relative below:
B.
Will the "serious medical condition" require hospitalization of
either the employee or the qualifying relative?
Yes
No
I certify that the information provided is correct to the best of my
knowledge.
Employee Signature
Date____________________
REQUEST FOR FAMILY/MEDICAL LEAVE OF ABSENCE
This form is to be completed by the EMPLOYEE requesting a paid or unpaid
leave of absence under provisions of the federal "Family and Medical Leave
Act of 1993" and City of St. Louis Administrative Regulation No. 133.
This
form should be completed and submitted to the Appointing Authority at least
thirty (30) days in advance of the beginning of such leave, except in those
cases where the nature of the medical/family emergency precludes such advance
notice.
1.
EMPLOYEE NAME: _________________________________________________________
2.
JOB TITLE: _____________________________________________________________
3.
DEPARTMENT:
4. DIVISION/SECTION:____________________
5.
REQUESTED LEAVE PERIOD:
From
To _____________________
6.
PAID LEAVE REQUESTED:
_________________________________________________
7.
I request Family/Medical Leave for the following reason:
For a personal serious health condition which renders me unable to
perform the functions of my job
For the anticipated birth and care of a newborn son/daughter
For the placement and/or care of a newly adopted child or foster
child
To care for the following qualifying relative with a serious health
condition (check one):
Legal spouse
Parent (includes natural or adoptive parent, stepparent, legal
guardian; does not include in-laws)
Person with "in loco parentis" status to the employee when the
employee was a child
Son or Daughter (includes natural, adoptive or foster child, or
stepchild, who is either under 18, or age 18 or older and
incapable of self-care because of a mental or physical
disability)
Child for whom employee has status as "in loco parentis"
8.
If the requested leave is for the birth or adoption of a child, or the
placement of a foster child, does your spouse also work for the City of
St. Louis?
Yes
No
9.
If the request for leave involves a "serious medical condition" of
either the employee or a qualifying relative, complete the following:
A.
If the employee will be providing care for a qualifying relative,
please print the full name of the relative below:
B.
Will the "serious medical condition" require hospitalization of
either the employee or the qualifying relative?
Yes
No
I certify that the information provided is correct to the best of my
knowledge.
Employee Signature
Date____________________
APPOINTING AUTHORITY RESPONSE TO
REQUEST FOR FAMILY/MEDICAL LEAVE OF ABSENCE
This form is to be completed by the APPOINTING AUTHORITY within five (5) business days of
receipt.
Determinations reached must comply with the provisions of the City of St. Louis
Administrative Regulation No. 133, "Family/Medical Leave."
This original form should be
submitted to the Department of Personnel, Employee Relations Section, with the "Employee
Status Form" (if necessary) placing the employee on leave and any medical or supporting
documentation required, at least thirty (30) days in advance when foreseeable of the date
leave begins; a copy of the completed form should be given to the employee.
1.
APPOINTING AUTHORITY RESPONSE:
Your request is approved as submitted, subject to providing the supporting
documents (if any) checked under Item 4 below.
Your request is approved under revised terms as outlined under Item 2 below,
The terms and conditions of your request were reviewed with the Department of
Personnel.
Your request is denied for the reasons outlined under Item 3
below.
2.
REVISED TERMS OF LEAVE (if any):
(usually limited to delay of the start of leave
due to employee's failure to provide either thirty (30) days advance notice in
foreseeable situations, or required documentation within fifteen (15) days of
request by appointing authority; can be a mutually agreed upon revision between the
employee and the appointing authority, such as paid leave granted)
___________________________________________________________________________________
___________________________________________________________________________________
3.
REASON FOR DENIAL: (if applicable)
Employee is ineligible for family/medical leave
Reason for leave outlined on reverse side of this form does not qualify for
family/medical leave
Failure to supply requested documentation, or documentation submitted does
not support eligibility for family/medical leave
Other: _____________________________________________________________________
4.
NOTICE TO EMPLOYEE OF SUPPORTING DOCUMENTATION REQUIREMENTS:
Completion of "Certification of Physician or Practitioner" form (employee
should be provided with a copy of this "Certification" form) to document
medical condition(s) supporting leave request
Proof of the expected date of birth or placement of a child
Proof of an "immediate family member's" qualifying relationship to the
employee requesting family/medical leave
"Fitness for duty" statement from a physician/practitioner (required before
the employee will be allowed to return from a leave of absence due to a
personal serious health condition)
Other: ____________________________________________________________________
Appointing Authority Signature
Date_____________________
Date copy was forwarded to employee:_____________________________________________________
Dept. #123 Revised 12-09
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