Page 49 - City of Farmington Administrative Regulations

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R <QlJ :,. 'I '•OU FAiVlff,Y~ 'flW ICAL L •'AV.IJ;

Employee Name: ------------ --
Date of Request: --------------

Department:------- - ---- ----
Title: ----------------

HireDate: ----- - - - - ------
I request a Family/Medical Leave for the following reason (check one):

A The birth of a child and in order to care for such child or the placement of a child for
adoption or foster care.
B. In order to care for an immediate family member if such family member has a
serious health condition, Circle one: CHILD ·SPOUSE· PARENT (Must submit
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"Physician or Practitioner Certification within 15 days)
_ c. Employee's own seri011s health condition that make.ii the employee unable to
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perform the functions of his/her position. (Must submit Physici.lln or
Practitioner Certification" within 15 days)
M thQd ofLeiiYe Rcqucslcd
A Consecutive Leave
B. Intennittent or Reduced Leave Schedule (Specify Schedule Below)

Date leave is to begin: ----- Expected duration of leave: ------
Designation for Use of Accruals (numbered in order of preference):
Sick Leave __ _vacation Leave _Comp Time (hourly employees only)
If the duration ofmyfarnily/medical leave (total of paid and unpaid time) does not exceed
12 weeks, I will be returned to my same or equivalent position. I understand that if my
family/medical leave should exceed 12 weeks I will be returned to my same or similar position,
only if available, in accordance with applicable laws. Ifmy same or similar position is not
available, I understnnd that I may be terminated.

I further understand that if! am covered under the City's Group Health Plan, that I will be
responsible forthe payment of premiums, depending upon the duration of my 1 eave. I will remain
in reasonable contact with the Insurance and Benefits Division to maintain cove.rage under the
City's plan.

Date.
Employee Signature

Family & Medical Leave Ferm A

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