Leander Independent School District
204 W. South Street
P.O. Box 218
Leander, Texas 78646
(512) 570-0000
TEMPORARY DISABILITY LEAVE REQUEST
Name (Print):
Employee Number:
Campus/Department:
Position:
I formally request Temporary Disability from employment with the Leander Independent
School District. This notice must be accompanied by the Department of Labor Form WH-
380-E, Certification of Health Care Provider for Employee’s Serious Health condition.
Temporary Disability Leave may not exceed 180 calendar days for employees whose
position requires a SBEC certification, or 90 calendar days for all other employees. I
understand that once I have exhausted any paid leave that I may have, the Temporary
disability Leave is without pay. If leave will be more than 5 consecutive days, a Family
Medical Leave Act Form (FMLA), if you qualify must be attached.
Reason for request:
Date Leave is to begin:
Date of expected return to duty:
Employee Signature:
Date: