Family & Medical Leave Act
The FMLA requires employers to provide up
to 12 weeks per year of unpaid Family and
Medical Leave to eligible employees, and to
restore those employees to the same or
equivalent positions upon their return.
Employee must be employed by the district
for at least 12 months and 1250 hours during
the previous 12 month period to be eligible
12 Month Period
The 12 month period shall be measured
backward from the date an employee uses
Example: Employee begins absence for a
serious illness on 3/1/03. The 12 month
period for determining FMLA eligibility looks
back to 3/1/02. If during this time an
employee had already used 6 work weeks of
FMLA, they would be eligible to use an
additional 6 work weeks for the current
Integrating FMLA With
District’s Leave Policies
Runs concurrently with district leave policies,
Local sick leave
State sick leave
State personal leave
Sick leave bank
Extended sick leave
Workers’ compensation leave
Uses for FMLA
Leave may be used for:
Adoption or placement of foster care of
Care of a seriously ill child, spouse or
Employee’s own serious illness
Intermittent Leave for Child Care
Shall not be permitted for the care of a
newborn child or upon the adoption or
placement of a child with the employee.
Forms Required for FMLA
For an absence of at least 7 consecutive
calendar days (5 work days) an employee
Long Term Absence Request Form (LTAR)
Certification of Health Care Provider Form
Both forms are available on the Q: drive,
Personnel folder, Forms folder.
Medical Certification Form
Employee must provide medical
certification of an illness or disability
when applying for FMLA.
Updated medical certification is required
at 30 day intervals.
Return to work requires medical
certification of the employee’s ability to
perform essential job functions.
When to Collect Forms
Prior to the beginning of the leave, if it
is a planned leave.
Within a week of the beginning of the
leave, if it is unplanned leave.
Approval of Long Term
Absence Request Form
Supervisor is responsible for:
Verifying types of leave for which the
employee is eligible
Verifying receipt of Certification of Health
Care Provider Form (CHCP). Original to be
retained by supervisor.
Verifying copies have been sent to Payroll
Office, Benefits Office (for W/C absences
Notification of Approved FMLA
Provide a copy of LTAR form signed by the employee
and supervisor to the employee within 2 business
days of receipt of application for FMLA.
If the employee does not provide a signed copy of
the LTAR and CHCP forms within 2 weeks of
beginning date of illness, send a copy signed by the
supervisor to the employee’s home address by
regular mail and certified mail.
This will serve as proof of notification that the leave
was applicable to FMLA from the first day absent in
the event of an audit.
Temporary Disability Leave
All certified full-time employees unable to
return from FMLA must submit a request for
Temporary Disability Leave, whenever all
leave available under FMLA has been
Supervisors are required to inform Personnel
when all leave has been depleted and the
employee is unable to return to work.
Benefits will remain in effect during an FMLA covered
absence. The district’s portion of the premium will
continue to be funded; however, the employee is
responsible for their portion, regardless of whether
they are receiving a paycheck. Failure to submit
premium will result in loss of coverage.
If the employee is unable to return to work at the
end of FMLA and other paid leave absences, the
Benefits Department will offer COBRA for the
employee to continue the insurance coverage, if the
premiums are current.
Confidentiality of Information
The AFD, LTAR and CHCP forms contain
confidential information regarding an
employee’s or a family member’s personal
health information that must be protected.
Shred any documents that are not necessary
for required record keeping that contain an
employee’s name, social security number, or
any medical information.
The FMLA statute requires that all
records be maintained in separate files
than the personnel files because the
documents contain personal health
Regulations require documents be
retained for a minimum of the current
fiscal year + 4 previous school years.
Non-compliance with these policies may
result in loss of revenue by the district.
If an employee’s medical claims exceed the
district’s stop loss amount will be subject to
audit to verify that all procedures have been
If procedures have not been followed
correctly and timely, the stop loss carrier may
deny reimbursement to the district for the
excess claims over the stop loss limit.
For more detailed information, please
Board Policy, DEC Legal and DEC Local
Secretaries’ Instruction Handbook