Employee Request for Leave Form - HeightsNET Employee Extranet

Please complete the form below if you have either been absent or anticipate being absent more than five workdays from work due to your serious health condition, or to care for a family member because of their serious health condition, or are welcoming a child (whether the days are taken intermittently, consecutively, or both).

Once Human Resources receives your completed form, we will follow up with any additional information the district needs to consider your leave request and provide you with any relevant details about your requested leave.

Employee Namerequired

First Name

Last Name

REASON FOR LEAVE

I am requesting leave for the following reason:

Personal

For a serious personal health condition that makes me unable to perform the essential functions of my job.

Describe health condition here:

Family

To care for a spouse, child, or parent with a serious health condition.

Name of the family member/relation to you:

If the family member is a child, are they under 18 years of age

Yes

No

Describe health condition here:

Birth

To attend the birth of a child, or the placement of a child with you for adoption or foster care and to bond with the newborn or newly placed child.

Expected date of birth, adoption, or foster placement:

Family Active Duty Call/Order

To attend a qualifying exigency arising out of the fact that your spouse, child, or parent is on covered active duty and has been notified of an impending call or order to covered active duty with the Armed Forces.

Name of the family member/relation to you:

Military Caregiver Leave

To care for a spouse, child, parent or next of kin of a covered service member with a serious injury or illness.

Name of family member/relation to you:

DESCRIPTION OF LEAVE REQUESTED

Dates of Requested Leave:

Are you requesting intermittent leave?

Yes

No

Not Applicable

If yes, describe the schedule you are proposing:

Are you requesting reduced work hours leave?

Yes

No

Not Applicable

If yes, describe the schedule you are proposing:

Date you will return to work:

MINNESOTA PAID LEAVE

Click here to read more about MPL qualifying events, coverage eligibility, and employment protections: https://mn.gov/deed/paidleave/employees/

Click here for additional info on MPL

Will you be applying for benefits under the Minnesota Paid Leave program?

Yes

No

Will your application for benefits under the Minnesota Paid Leave program be for both the birth of a child (medical leave) and subsequently the bonding with the newborn beyond 12 total weeks of leave?

Yes

No

If yes, and your application is approved by MPL, are you planning to supplement the MPL benefits with any available paid time off you have in your district leave banks (ESST, sick, vacation, etc.)?

Yes

No

If you would like to supplement the MPL benefits with your paid time off, please describe here how you would like your paid leave applied (for example: only apply up to 10 of my sick days, stop applying my sick days after this date, stop applying my sick days after a certain number of days absent on leave).

*Please note that leave taken pursuant to MPL shall run concurrently with FMLA leave, Minnesota Pregnancy and Parental leave and any other similar leaves approved by the School District.

Are there any additional notes or questions about your leave for Human Resources?0 / 1000