Online Student Application

Questions

1. Title
2. Department
3. Hire Date
4. Requested Leave Start Date
5. Estimated End Date
6.  

   The reason for the FMLA Leave of Absence request is (select the most appropriate choice) * (Selection is Required)

   Birth of my child and to care for my newborn child. (Submit Certification of Health Care Provider Form)

   Placement with me of a child for adoption or foster care. (Submit adoption or placement documentation as Certification) (Specify Below)

   My own serious health condition that makes me unable to perform functions of my job. (Submit Certification of Health Care Provider Form)

   To care for my spouse, child, or parent with a serious health condition. (Submit Certification of Health Care Provider Form)

   State relationship of family member to you: (Specify Below)

   To care for a covered servicemember with a serious injury or illness that is my spouse, child, parent, or next of kin. (Submit Certification of Military Caregiver Leave Form)

   State relationship of family member to you: (Specify Below)

   A qualifying exigency arising out of the fact that my spouse, child, or parent is a military member on covered active duty in a foreign country (or has been notified of an impending call or order to covered active duty status). (Submit Certification of Military Family Leave for Qualifying Exigency Form)

   State relationship of family member to you: (Specify Below)

   COVID-19 Quarantine: I have been exposed to some with COVID-19 and need to quarantine. (Submit directive to quarantine from Alexander health Center (AHC) as certification)

   (Specify Below)

   • Date of exposure
   • Date of Scheduled COVID-19 test
   • Quarantine ends upon a negative COVID-19 test or the end of the quarantine period as provided by AHC.

   COVID-19 and childcare: To care for my child when I am unable to work (or telework) due to the closing of my child's school, place of care, or unavailability of regular childcare provider due to public health emergency with respect to COVID-19.

   (Certification needed includes following questions) (Specify Below)

   • Name and age of children
   • Name of school/daycare provider
   • If your child(ren) is above age 14, please explain special circumstances that require your need for leave to care for your child(ren)
   • No other suitable person is available to care for my child(ren) for the requested leave period due to (list reason)

   Additional Note or Comment
7.  

   My time off work is expected to be (select the most appropriate choice): * (Selection is Required)

   For a continuous block of time (several continuous days, weeks, or months off work).

   For Rest and Recuperation (R&R) of the military family member (leave for this reason is limited to fifteen (15) calendar days for each instance of R&R leave).

   For a reduced work schedule (change in work schedule needed - fewer hours per day or fewer hours per week).

   (Specify Below)

   • Please explain why a reduced work schedule is needed
   • Provide your best estimate of the reduced schedule you are able to work

   On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week; examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatments/appointments).

   (Specify Below)

   • Please explain why intermittent leave is needed
   • Provide your best estimate of the frequency and duration of each appointment, meeting, or leave event including any travel time:
     • Number of times per (day, week, or month);
     • and are likely to last (number of hours or days) per episode.

   Additional Note or Comment
8.  

   Benefits participation during unpaid FMLA Leave of Absence (please select an answer below regarding benefits) * (Selection is Required)

   I wish to continue the group insurance coverage during my leave of absence. I understand that it is my responsibility to contact Human Resources Services regarding the amount of premiums due and to make such arrangements. I further understand that I must pay the normal employee contribution due each month to avoid suspension and/or cancellation of my coverage.

   I do not wish to continue the group insurance benefits during my leave for the following reasons: (Specify Below)

   Additional Note or Comment