Leave of Absence Request Form -metropolitan Public Schools

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LEAVE OF ABSENCE REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
EMPLOYEE NAME: ____________________________________________________ ID# ____________
(
Please Print)
Address:________________________________________________________________________________
(Street)
(City)
(ST)
(Zip)
(Home)
Job Title: ________________________________ Phone: ________________ Cell: __________________
.: _____________________
_________________
_______________
School or Dept
Principal or Supervisor
Timekeeper
I request
continuous
or
intermittent
leave of absence for the following reason:
 due to my own serious health condition.
 due to the birth of my child. The child was/will be born on or around ______/______/______.
 to care for my recently adopted or recently placed foster child. Child’s name: ___________________.
The child was/will be born/adopted/placed on or around _______/_______/_______.
 to care for my spouse, child, or parent who has a serious health condition. Name of family member:
__________________________. Relationship: ________________________________.
 to fulfill my obligations to the uniform services (military leave).
 my spouse/son/daughter/parent is on or has been called to active duty (military exigency leave).
 to care for my family member who incurred a serious health condition/illness while on active military
duty (military caregiver leave).
Other (explain) ___________________________________________________________________
Expected Beginning Date: _______/_______/_______ Expected Return Date: _______/_______/_______
NOTE: It is the employee’s responsibility to keep Employee Benefits informed of any Leave status changes
and to ensure that all Leave of Absence procedures are complied with. Please see the “Family and Medical
Leave Policy” for more information.
Employee Signature: ______________________________________
Date: _______/_______/________
TO BE COMPLETED BY EMPLOYEE BENEFITS
 Approved
Sick
Maternity
FMLA
Military
Other_________________________________
 FMLA Denied – Reason:
 Ineligible  FMLA exhausted  Incomplete Physician’s certification
 Other __________________________________________
Employee Benefits: __________________________________________ Date: _______/_______/________
 Date of hire _______/_______/______
 Supervisor notified
 Payroll notified
 Physician’s Certification rec’d _______/_______/______
PLEASE RETURN FORM TO METROPOLITAN PUBLIC SCHOOLS /EMPLOYEE BENEFITS DEPT.
2601 BRANSFORD AVE, NASHVILLE TN 37204 PHONE 615-259-8641 (Julie) or
615-259-8410 (Karen)
* FAX 615-214-8665.
LEAVE OF ABSENCE REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
EMPLOYEE NAME: ____________________________________________________ ID# ____________
(
Please Print)
Address:________________________________________________________________________________
(Street)
(City)
(ST)
(Zip)
(Home)
Job Title: ________________________________ Phone: ________________ Cell: __________________
.: _____________________
_________________
_______________
School or Dept
Principal or Supervisor
Timekeeper
I request
continuous
or
intermittent
leave of absence for the following reason:
 due to my own serious health condition.
 due to the birth of my child. The child was/will be born on or around ______/______/______.
 to care for my recently adopted or recently placed foster child. Child’s name: ___________________.
The child was/will be born/adopted/placed on or around _______/_______/_______.
 to care for my spouse, child, or parent who has a serious health condition. Name of family member:
__________________________. Relationship: ________________________________.
 to fulfill my obligations to the uniform services (military leave).
 my spouse/son/daughter/parent is on or has been called to active duty (military exigency leave).
 to care for my family member who incurred a serious health condition/illness while on active military
duty (military caregiver leave).
Other (explain) ___________________________________________________________________
Expected Beginning Date: _______/_______/_______ Expected Return Date: _______/_______/_______
NOTE: It is the employee’s responsibility to keep Employee Benefits informed of any Leave status changes
and to ensure that all Leave of Absence procedures are complied with. Please see the “Family and Medical
Leave Policy” for more information.
Employee Signature: ______________________________________
Date: _______/_______/________
TO BE COMPLETED BY EMPLOYEE BENEFITS
 Approved
Sick
Maternity
FMLA
Military
Other_________________________________
 FMLA Denied – Reason:
 Ineligible  FMLA exhausted  Incomplete Physician’s certification
 Other __________________________________________
Employee Benefits: __________________________________________ Date: _______/_______/________
 Date of hire _______/_______/______
 Supervisor notified
 Payroll notified
 Physician’s Certification rec’d _______/_______/______
PLEASE RETURN FORM TO METROPOLITAN PUBLIC SCHOOLS /EMPLOYEE BENEFITS DEPT.
2601 BRANSFORD AVE, NASHVILLE TN 37204 PHONE 615-259-8641 (Julie) or
615-259-8410 (Karen)
* FAX 615-214-8665.

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