Please circle type of leave(s) you are requesting: FMLA Medical Disability Adoption Child Rearing

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1 PENNSBURY SCHOOL DISTRICT Human Resources Department 134 Yardley Avenue, Fallsington, PA Phone: (215) Fax: (215) MEDICAL/DISABILITY/MATERNITY/ADOPTION/CHILD REARING LEAVE Name: Position: Home Address: School/Building: Phone Extension: Home Phone Number: Home Address: Projected Last Day of Work: Anticipated Date of Return: Please circle type of leave(s) you are requesting: FMLA Medical Disability Adoption Child Rearing SICK DAYS Do you wish to use Sick days during all or part of your leave period? Yes No If so, indicate the number of sick days you wish to use: Sick days can only be used during the leave period and must be verified by a doctor s note. Do you wish to use Personal Business days during all or part of your leave? Yes No Please attach a doctor s note to this form or send it to the Human Resources Department certifying your condition including approximate due date for maternity and approximate length of medical/disability period. Upon return to the District, a doctor s note certifying that you may return to your full duties is required. COBRA After your covered district health insurance period ends, would you be interested in continuing at your own expense, any portion of the District health benefits under COBRA? Yes, I would like to purchase benefits. No, I am not interested N/A - Not currently covered by Pennsbury ADDITIONAL INFORMATION FOR MEDICAL/DISABILITY/MATERNITY/ADOPTION/CHILD REARING LEAVE As per School Board Policy, the Family Medical Leave which covers employees under Pennsbury Health Insurances begins the first day of the leave (paid or unpaid) and continues for a maximum of twelve (12 weeks) in a one-year period. To qualify for a FMLA you must have worked for the employer for at least 12 months and you must work at least 1250 hours in the 12 months before you take a leave. You would need to pay cost sharing during this time to keep your benefits. This means that during this time, your insurances will be covered by the school district. Do you wish to take an unpaid leave of absence to care for your child after the Family Medical Leave period ends? Yes No Anticipated Date of Birth/Adoption of Child: In the absence of medical necessity, at least sixty (60) days notice of intent to take such leave shall be given by the applicant. Signature: Date: Send completed form to the Human Resources Department. Should there be a need in the future to make a change, you must do so in writing.

2 1. What is a Child Rearing Leave? DISABILITY/MATERNITY/ADOPTION/CHILD CARE/FMLA PART I CHILD REARING LEAVE It is an unpaid Leave of Absence following the birth or adoption of a child. The maximum period of the leave shall be a period of one (1) year after the leave has begun. Requests for an extension for an additional period of up to one (1) may be granted at the sole discretion of the District. For further information, see page 10 of the Collective Bargaining Agreement. 2. How do I apply for Child Rearing Leave? You need to complete a form for Disability/Maternity/Adoption/Child Rearing Leave available in the Human Resources Department and also available on the website of the Human Resources Department at Then send such form to the Human Resources Department at least sixty (60) days prior to the effective date of the leave. 3. How can I extend my Child Rearing Leave? Send a letter or report to the Office of Human Resources at least sixty (60) days prior to the conclusion of the previously approved Child Rearing Leave. 1. What is FMLA? PART II FAMILY MEDICAL LEAVE ACT (FMLA) FMLA is a Federal law that requires covered employers to provide up to twelve weeks of unpaid job protected leave to eligible employees for certain family and medical reasons. Employers must also allow eligible employees to take up to 26 weeks of leave during a 12-month period to care for a spouse, child, parent, or next of kin who is a covered service member recovering from a serious injury or illness suffered in the line of active military duty. The covered service member must be an outpatient or on the temporary disability retired list. 2. What are the reasons for taking a FMLA leave? To care for the employee s child after birth, or placement for adoption or foster care. To care for the employee s spouse, son or daughter, or parent who has a serious health condition. For serious health condition that makes the employee unable to perform the employee s job. For a qualifying exigency if the employee s spouse, son, daughter or parent is on active duty or has been notified of an impending call or order to active duty in support of a contingency operation. 3. Who is eligible to take Family Medical Leave? Employees are eligible to take FMLA leave if they have worked for the District for at least twelve (12) months and have worked for at least 1250 hours over the previous twelve (12) months. The 1250 hours include only hours worked for the District. Paid leave and unpaid leave are not included in 1250 hours. 4. How much leave am I entitled to under FMLA? If you are an eligible employee, you are entitled to up to twelve (12) weeks of leave for certain family and medical reasons during a twelve (12) month period. 5. How is the twelve (12) month period calculated under FMLA? The Pennsbury School District uses the rolling twelve (12) month period measured backward from the date an employee uses FMLA leave.

3 6. Does the law guarantee paid time off? No. FMLA only requires unpaid leave. However, the law permits an employee to elect to use accrued paid leave, such as vacation or sick leave, for some or all of the FMLA leave period. When paid leave is substituted for unpaid FMLA leave, it will be counted against the twelve (12) week FMLA leave entitlement. 7. What is charged to FMLA? FMLA can be requested by the employee (30 days notice is required unless there is an emergency situation). If an eligible absence from work lasts beyond five (5) consecutive days, that time would be charged to the eligible employee s Family Medical Leave Act entitlement. This includes absences for reasons of personal illness as well as work-related illness including those that are covered under workers compensation. 8. If I plan to use FMLA leave for pregnancy and child rearing but need leave due to pregnancy complications, does this additional leave count towards my FMLA leave? Yes. An eligible employee is entitled to a total of twelve (12) weeks of FMLA leave in a twelve (12) month period. If the employee has to use some of that leave for another reason, including a difficult pregnancy, it will be counted as part of the twelve (12) week FMLA leave entitlement. This includes time away from work due to pregnancy disability as well as maternity leave. 9. Who is an immediate family member for purposes of taking FMLA leave? An employee s spouse, child, and parents are immediate family members for purpose of FMLA. The term parent does not include a parent in-law. The terms son or daughter do not include individuals age 18 or over unless they are incapable of self-care because of mental or physical disability that limits one or more of the major life activities as those terms are defined in regulations issued by the Equal Employment Opportunity Commission under the American with Disabilities Act. 10. What documentation is required to apply for FMLA leave? In order to apply for an FMLA leave, a medical certification from a treating physician is required indicating that the employee or immediate family member is suffering from a serious health condition which prevents the employee from working either on a consecutive basis or intermittent basis. Medical certification is also required in order to care for an immediate family member. Forms are available in the Human Resources Department for employee use. Medical certifications for personal illness need to include both the effective date of the leave as well as either the next treatment date or return to work date. 11. Once my twelve (12) weeks of FMLA leave expires, what can I do? Leaves of absence for medical conditions and child rearing are covered in your contract. You must follow the guidelines as set forth in your bargaining unit agreement. 12. Can I maintain my health insurance during the FMLA leave? Yes, during the twelve (12) week FMLA leave, your health insurance coverage will continue under the same circumstances as previously provided. 13. Can a FMLA leave be taken on an intermittent basis or to work a reduced schedule? Yes, as long as you continue to qualify for a FMLA leave. 14. If I become eligible for a FMLA leave during the summer when school is not in session, when does my FMLA leave begin? The FMLA leave would begin with the new school year. 15. If I become eligible for a FMLA leave during a scheduled holiday recess period when school is not in session, when does my FMLA leave begin? The FMLA leave would begin on the first scheduled workday following the holiday recess period.

4 16. Do I need to take the entire twelve (12) weeks when on a FMLA leave? No, you may voluntarily stop your FMLA leave prior to the expiration of the twelve (12) week period. Should the qualifying event which entitles you to the FMLA leave continue at a future date, you then would be eligible to use the remainder of your twelve (12) week FMLA leave. 17. Does a scheduled holiday recess period count against the twelve (12) weeks of FMLA leave? No, only workdays count as part of the twelve (12) week FMLA leave. 1. What is a disability leave due to maternity? PART III DISABILITY/MATERNITY LEAVE It is a Leave of Absence due to the birth of a child. 2. Do I need a Doctor s verification to take such a leave? Yes, you must submit a Doctor s verification indicating the reason for the disability and the length of the leave. This verification must be sent to the Human Resources Department and attached to the application for the leave. 3. May I use paid sick days during the maternity leave? Yes, up to the number of sick days you have accumulated and with proper Doctor s verification. 4. If I do not have enough sick days to cover the disability period or if I prefer not to take all of my sick days, may I take all or part of this leave on an unpaid basis? Yes; however, this still requires a Doctor s verification. 5. What is the length of the Maternity Leave? The length is determined by your disability period as determined by your Doctor. 6. How do I apply for a Maternity Leave? You need to complete a Disability/Maternity/Adoption/Child Care Leave form by sending the completed form to the Human Resources Department forty-five (45) days prior to your first day of absence. Also attach your Doctor note verifying your disability to this form. 7. What do I need to do to return from a Maternity Leave? You must give notice of intention to return to the Human Resources Department. You also must provide a Doctor s note prior to your return indicating that you are physically capable of fully returning to your job duties. 8. Following the birth of my child, how do I add him/her to my insurance coverage? It is important that you add your newborn immediately after the birth of the child to your insurance coverage. You may do so by ing your name, the newborn s name, and newborn s date of birth or calling the Human Resources Department and obtaining and completing an enrollment form and returning it to the Human Resources Department.

5 PART IV GENERAL INFORMATION FOR ALL LEAVES 1. Am I guaranteed my position when I return from leave? Upon termination of the leave, the District shall reinstate the employee to the position held prior to the leave if available, or to a substantially equal position if such position is available. If such position is not available, you may be offered any other available position for which you are qualified. 2. How does an unpaid Leave affect my salary step for the year I return from leave? An unpaid Leave affects benefit time eligibility, but does not affect step movement if the employee was eligible before the unpaid leave. 3. If I return from such leave during the course of a school year, how does this affect my salary step for the following year? An unpaid Leave affects benefit time eligibility, but does not affect step movement if the employee was eligible before the unpaid leave. 4. Are my personal or sick days pro-rated while on leave? Your personal days are pro-rated if you have taken an unpaid leave of absence. Sick leave days may be prorated based upon the date of your leave and return. If you are a 12-month employee, vacation days are pro-rated based on the total amount of months worked in the year during which you took an unpaid leave. 5. How do unpaid leaves affect my seniority and retirement? Your seniority date is adjusted based upon the number of unpaid days you are on leave. Since no retirement will be deducted from your pay, you will not be given retirement credit for any unpaid leave. 6. How do I continue to pay for my insurance coverage during an unpaid leave? You need to contact the Human Resources Department to obtain information regarding your insurances. You will then be required to send a check to the Human Resources Department. 7. Am I eligible for tuition reimbursement when I am on an unpaid Leave of Absence? No, only active employees are eligible for tuition reimbursement. Disclaimer Although the committee of Human Resources professionals and Union Member representatives have taken reasonable precautions to ensure that the information in the Q & A packet does not contradict the language in the collective bargaining agreement ( CBA ) between the Pennsbury School District and the Pennsbury Educational Support Professionals Association, conflict may still exist. This packet acts as a guide for eligible employees and does not take the place of the CBA. The language in the CBA shall take precedence over any language in the Question and Answer packet