Family Medical Leave Act Employee Request For Leave Form - Leander Independent School District Page 2

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:

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