Leave of Absence Request Form

LEAVE REQUEST FORM

Please review the information below and complete the form and upload any physician documentation. For questions, contact Julian Alexander in Risk Management at 281-498-8110 ext. 29153 or riskmgnt@aliefisd.net.
Family Medical Leave Act (FMLA - leave is protected)

FMLA is for employees employed by the District for 12 months, and the employee has worked 1250 hours in the 12 months immediately preceding the need for leave. If this leave is for maternity, illness of a member of the immediate family (mother, father, spouse, and children) or illness of self. The term parent does NOT include a parent “in-law”. The term son or daughter does include individuals 18 years or over, if they are “incapable of self-care” because of mental or physical disability that limits one or more of the “major life activities”.

Maximum duration: 12 work weeks

Intermittent or Reduced Schedule Leave

The District shall not permit use of intermittent or reduced schedule FMLA leave for the care of a newborn child or for the adoption or placement of a child with the employee. [See DECA(LEGAL) for use of intermittent or reduced schedule leave due to a medical necessity.]

Maximum duration: 60 workdays

Temporary Disability Leave (TDL - leave is not protected)

This leave is only for full-time employees who have exhausted FMLA or have been with the District less than one year. This leave is for the illness of the employee only.

Maximum duration: 180 calendar days

**All leaves are unpaid unless the employee has acculated local and state days for pay.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Employee ID Number*
Phone Number*
Personal Email*
do not use Alief email
Campus/Department*
Job Title*
Supervisor's Name*
Supervisor's or Secretary Email
example@example.com

Leave Request Information
First Day of Leave*

MonthDayYear
Date of Estimated Return*

MonthDayYear
Return date can be adjusted
I am requesting a (check one):*

Medical Leave (self/spouse/minor child/parent)Military Leave (self/spouse/child)Intermittent Leave of Absence (smaller blocks of time ranging from a few hours to a few days at a time) - (self/spouse/minor child/parent)

Reason for Request
Select one*

SelfFamily Member - (Spouse, Minor Child or Parent)
Is this for a pregnancy or adoption?*

YesNo
For Pregnancy or Adoption - anticipated date of birth or placement: Due Date or Placement Date*
For Intermittent Leave - Please provide an estimate of your leave dates of when you will be unavailable to work (only if eligible for FML). Day(s) or Hours*
Relationship of family member to you:   *   .
Provide date of birth of family member:   DOB*   .
Is leave due to an injury/illness associated with a family member’s military service?   Yes   No*

Signature & Acknowledgement
I acknowledge*

Alief ISD does not offer paid leave. An employee is paid for any accrued state and local days.Employee salary will be adjusted upon return if they do not have enough local or state days to cover the entire leave. Please contact your HR Record Specialist for additional information.Employees are responsible for their health insurance premiums while out on leave and will be invoiced if you're no longer receiving a paycheck. Insurance may be canceled if unpaid.The employee must obtain a medical release and submit it to Risk Management 2 days before returning to work. Employees will not be allowed to return to work without a release from the attending physician. All medical releases with restrictions/limitations must be reviewed and approved by Risk Management before the employee is released to return to work.It is the employee's responsibility to notify their supervisor of their leave request.In order to earn a year of membership service credit with TRS, you must work in a TRS-eligible position or receive paid leave from a TRS-eligible position for at least 90 days during the school year. For more information call TRS at 1-800-223-8778.It is the employee's responsibility to enter all absences into absence management for the duration of their medical leave
Type your Signature*
Medical documentation or note

You can submit without medical documentation, but it will be required within 15 days of request.
Cancelof
Medical Documentation Due

MonthDayYear
Should be Empty:

LEAVE REQUEST FORM