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FMLA/Parental Leave Request

EPS Wave Logo, shades of crimson and gold

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. 

FMLA Form: Employee

FMLA Form: Family Member

EPS Work Location
Answer required for "EPS Work Location"
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 for "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."
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 for "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. "
6. I understand I must furnish additional medical documentation if my leave needs to be extended due to medical reasons.*
Answer required for "6. I understand I must furnish additional medical documentation if my leave needs to be extended due to medical reasons."
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 for "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."
Please attach all relative supporting documents including the appropriate FMLA Form.*
Answer required for "Please attach all relative supporting documents including the appropriate FMLA Form."
or drag it here.
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