FMLA Request

Have you worked for DMPS 12 consecutive months or longer AND worked 1250 hours or more for DMPS? (Average of 24 hours or more a year) *
PLEASE REFER BACK TO YOUR SUPERVISOR FOR DIRECTION
AS YOU DO NOT MEET THE REQUIREMENTS FOR FMLA ELIGIBILITY
 
FTE: *
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If you are using intermittent leave use the fiscal year for your start and end dates. 
 
For example, your start date would be 07/01/2016 and your end date would be 06/30/2017.
PLEASE READ THE BELOW STATEMENT CAREFULLY: 
We need the accurate email addresss of your immediate supervisor to continue with this process.

Reason for Leave

Reminder:  You can use 3 family sick days and/or personal business, the remainder will be deduct.
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REMINDER:

You must add a newborn or adopted child in Benefitfocus

within 60 days of birth or placement.

STEP 1: Add child as a dependent and enter social security number.

STEP 2: EDIT your health plan, dental plan, and vision plan (if applicable) to include new dependent.

STEP 3: Upload copy of birth certificate or adoption decree.

If you have any questions, please contact the Benefit Department.

Does your reason for FMLA require an intermittent or reduced schedule? *
Is this a work related injury or illness? *
Full definitions and eligibility requirements for FMLA can be found here.

Health Care Provider Release

By checking this box, I hereby authorize the health care provider of the patient listed above to complete a health care provider certification and periodic re-certifications during my leave. *

Provisions and Signatures

I understand and agree to the following provisions:
 
  •  The FMLA Leave requested will be counted toward the 12 weeks allowed per fiscal year.
  •  To qualify for FMLA Leave, I have worked for my employer at least one year and at least 1,250 hours in the previous 12 months.
  •  If I fail to return to work for at least 30 calendar days after the FMLA Leave for reasons other than the continuation, reoccurrence or onset of a serious health condition that would entitle me to Medical Leave or other circumstances beyond my control, I will be financially responsible for medical insurance premiums the District paid while I was on leave.
  • This absence will be unpaid unless I have sick leave, vacation, emergency, personal time or holiday pay that I use as defined by each respective policy or I qualify for payment under Des Moines Public Schools' disability plan.
  • Vacation and sick leave accrual will cease during an unpaid FMLA leave.
  •  If I do not return to work or contact my supervisor on or before the expected return date, it will be considered that I have abandoned my job and have voluntarily terminated my employment with Des Moines Public Schools.
  • Des Moines Public Schools may contact my health care provider as provided under the Family Medical Leave Act. A second health care provider opinion may be requested.
  • I have received and read the applicable leave policy.
  • I am responsible for medical and otherĀ· benefit premiums during non-FMLA leave of absence.
 
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Confirmation of Electronic Signature: I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the information above. *

Alternative Contact

A copy of the Designation Notice (decision on FMLA) will automatically go to your DMPS email address. If you would like it to also be mailed to your mailing address listed in our financial system, please indicate that here.

Forms for Health Care Provider

You should receive a PDF with the Health Care Provider Certification but the links are here if needed: