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FMLA/Parental Leave Request

EVERETT PUBLIC SCHOOLS
Human Resources Deparment
Director: Elaine Monge

Please complete the form below. Required fields marked with an asterisk *

This is for internal use by Everett Public Schools, and completing and submitting this form
does not guarantee approval of your FMLA request.

Please complete the appropriate FMLA form (links below) and attach it to this request.
If you have any questions please contact the HR Department.

Click here for FMLA Form - Employee

Click here for FMLA Form - Family Member

Your Name*

Answer Required

Job Title*

Answer Required

EPS Work Location

Answer Required

Your EPS Employee ID Number

Answer Required

1. Please list the reason for your FMLA request.*

Answer Required

2. This leave will begin on:*

Answer Required

3. This leave will end on:*

Answer Required

4. I understand that my health benefits must be maintained during any period of unpaid leave under the same conditions as if I continued to work.*

Answer Required

I understand and accept these terms

5. I understand that I must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on my return from leave. *

Answer Required

I understand and accept these terms

6. I understand I must furnish additional medical documentation if my leave needs to be extended due to medical reasons.*

Answer Required

I understand and accept these terms

7. I understand that if my leave is for my own medical condition, I will be required to furnish a fitness for duty letter from my health care provider before I may return to work.*

Answer Required

I understand and accept these terms

Please attach all relative supporting documents including the appropriate FMLA Form.*

Answer Required

Choose a file or drag it here.

Confirmation Email

Confirmation Email *

Email Required