request for family leave

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					                                   Georgia Public Defender Standards Council
                                    Family and Medical Leave Request Form
                                                       (Please type or print clearly in ink)

                                                          EMPLOYEE IDENTIFICATION
                                                                             Circuit
 Social
 Security
 Number                                                                      Work Address


 Last Name                      First Name                     Initial       Employee’s Job Title


 Street Address, Apartment/Box/Route                                         Employee’s Supervisor


 City, State                            Zip Code (5 digit + 4 digit)         Home Telephone Number


                                                                REQUESTED DATES
     I am requesting Family and Medical Leave as indicated: Beginning ____________Probable Ending _______________
     I am requesting my previously approved Family Leave be extended through ___________________________________

 During my Family and Medical Leave, I am requesting that my absence be handled as follows:
 Type of Leave               # of Hours                    Beginning                    Ending
 Sick
 Annual
 Leave Without Pay
                                           TYPE OF LEAVE REQUESTED
  Birth of a Child                                                           Adoption or Foster Care
      Name of mother __________________________                                    (Attach documentation)
                                                                                   Date of Placement with employee ________________
      Due Date _______________________________                                     Name of child ________________________________

  Care of a Family Member
      Family Member’s Name _________________________________________

      Relationship: ____ Dependent Child           ____ Spouse           ____ Parent


  Employee’s Serious Health Condition
      Serious health condition is defined as an illness, injury, impairment or physical or mental condition that involves continuing
      treatment by a health care provider, inpatient care in a hospital, hospice, or residential medical facility that makes the
      employee unable to perform the functions of his or her job for three days or more. For a more detailed definition, see the
      attached.

I am requesting family and medical leave for the reasons indicated above. I have attached the appropriate documentation
(certification by a health care provider on the back of this request, or documentation of adoption or foster care).



Employee’s signature                                                                            Date

                                           Human Resources Manager Response
I have reviewed your request for Family and Medical Leave. Your request is: Approved                       Modified*     Denied*

 ______________________________________               ________________________________________________________
 Date                                                 Signature
(*Attach explanation and Notice of Right of Appeal)
***Please note that approval of this request does not constitute approval of paid leave or extension of coverage under
the State Health Benefit Plan.***


GPDSC/HR/REV. 8/16/2006
                                     CERTIFICATION BY HEALTH CARE PROVIDER*
GPDSC employees: Please have this form completed by your (or your family member’s) health care provider and
return it to the Human Resource Manager as soon as possible before your leave begins, or within two business days of
the commencement of leave when the need for leave is unforeseeable. If the reason you are requesting leave is your
own serious illness, please provide your health care provider with a copy of your job description.

Health Care Provider: This information will be used to determine eligibility for absence from work for family and
medical leave purposes in accordance with the Family and Medical Leave Act of 1993, and to determine eligibility for
paid leave. Please read the definition of serious health condition (attached) before completing this form if you are not
familiar with the definition as used in the Act.

 Health Care Provider’s Name                                                Type of Practice


 Group Name                                                                 Street Address, Suite/Box


 Telephone Number                                                           City, State                           Zip Code (5 digits + 4 digits)


 Telephone Number                                                           Employee Name (if different)


                                                      CARE OF FAMILY MEMBER
 Date(s) Employee presence is necessary for care of family member:           Beginning __________ Probable Duration ___________

 If the patient will need care only intermittently or on a part-time basis, please indicate the anticipated frequency and duration of this need:

 ___________________________________________________________________________________

 Describe the medical facts supporting your certification of a serious health condition. Attach additional page(s) if necessary.
 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

                                         EMPLOYEE’S SERIOUS HEALTH CONDITION
 Date Disability                                                   Probable Duration
  Commenced: ______________________________                          or Ending Date: _____________________________

 Describe the medical facts supporting your certification of a serious health condition that requires the employee’s absence for treatment or
 makes the employee unable to perform the essential functions of his or her position. Attach additional page(s) if necessary.
 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 If any treatment will be provided by another health care provider (Physical Therapist, etc.) state the nature of the treatments and the type of
 provider that will be providing the care:

 ____________________________________________________________________________________________

 If the patient will need care only intermittently or on a part-time basis, please indicate the anticipated frequency and duration of recurring
 periods of incapacity and/or treatment:

 Is inpatient care required? Yes       No     . Is the patient unable to perform work of any kind? Yes        No
 If no, explain what duties the employee may perform (if the employee does not provide a job description, contact GPDSC HR at (404) 232-
 8900 for information about the employee’s job):



________________________________________                                   _____________________________________________
Date                                                                       Signature of Health Care Provider (No Stamps, Please)
*Health care provider is defined as: A doctor of medicine or osteopathy who is authorized to practice medicine or surgery (as appropriate) by the
State in which the doctor practices; or any other health care provider authorized by the State to diagnose and treat physical or mental health
conditions without supervision by a doctor or other health care provider.


GPDSC/HR/REV. 8/16/2006
                                     SERIOUS HEALTH CONDITION
A “serious health condition” is defined by the Family and Medical Leave Act of 1993 as an illness,
injury, impairment, or physical or mental condition that involves one of the following:

1.     Hospital Care
       Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including
       any period of incapacity (defined as the inability to work, attend school or perform other regular daily
       activities due to the serious health condition, treatment there for, or recovery there from) or subsequent
       treatment in connection with or subsequent 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 related to the same condition), that also involves:
              a. Treatment of two or more times (includes examinations to determine if a serious health
                  condition exists and evaluations of the condition. Does not include routine physical, eye, or dental
                  examinations) 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 (such as a physical
                  therapist) under order of, or on referral by, a health care provider, OR
              b. Treatment by a health care provider on a least one occasion which results in a regimen of
                  continuing treatment (includes a course of prescription medication nor therapy requiring special
                  equipment to resolve or alleviate the health condition; does not include over-the-counter
                  medications or activities that can be initiated without a visit to a health care provider, such as bed
                  rest, drinking fluids or exercise) 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; and
             b. Continues over an extended period of time (including recurring episodes of a single
                  underlying condition); and
             c. May cause episodic rather than continuing periods of incapacity (such as 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).




GPDSC/HR/REV. 8/16/2006

				
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