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Family Medical Leave Act Employee Request Form

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Type of Leave Being Requested
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For family health condition. Your family member is your:
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What type of FMLA leave are you requesting?
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Intermittent leave requires the employee to work with their supervisor to schedule their leave.

I hereby agree that while on leave, I will pay health insurance premiums unless I choose to stop coverage. If I don't return, I'll reimburse the District for health benefits provided during leave, except for serious illness or uncontrollable circumstances. I'll provide medical certification for serious health conditions.

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