City of Portland

FMLA/OFLA Leave of Absence Application

[ ] New Request [ ] Revision / Extension

Employee Information (Type or Print)

Name:       Personnel Number:      

Home Address:      

Home Phone:       Home Email (*optional):      

Bureau/Office:       Work Phone:      

Reason for Leave

[ ] Care of a newborn, adopted or foster child. Anticipated date of birth or placement:      

[ ] Employee’s own serious health condition (including pregnancy related disability)

[ ] Care for a family member with a serious health condition

Specify relationship:      

Family member’s name:      

If child, date of birth:      

[ ] Military Caregiver Leave

Specify Relationship:      

Family member’s name:      

[ ] Family Leave due to family member’s call to active duty

Specify Relationship:      

Family member’s name:      

[ ] OFLA Bereavement Leave Date employee notified of family member’s death:      

Family member’s name:      

Specify Relationship:      

Leave Request (Check all that apply)

[ ] Full Time/Continuous

Start date:      

End date:      

[ ] Reduced Work Schedule

Start date:      

End date:      

Estimate reduced schedule:      

[ ] Intermittent

Start date:      

End date:      

Estimate the frequency of absences/episodes:      

Estimate the approximate duration of each absence/episode:      

Request to reserve leave during family medical leave

If eligible, I elect to reserve       hrs. vacation       hrs. compensatory time (80 hours combined maximum)

Employee Acknowledgement

•  I understand that my leave may be delayed until the Medical Certification Form is returned if applicable.

•  I understand that in the case of my own serious health condition, I will not be permitted to resume my position with the City until I provide a completed Return to Work Release Form.

•  City policy requires employees use appropriate accrued leave before a period of unpaid leave.

•  I understand that I may not work elsewhere, including self-employment while on family medical leave.

•  I agree that while I am on leave, I will continue to pay my share of insurance premiums, if applicable, unless I elect to discontinue coverage. I also agree that if I fail to return to work at the end of the leave period, I will reimburse the City for its share of City-provided health benefits during my leave, unless I fail to return to work because of the continuation, recurrence, or onset of my own serious health condition, or by other circumstances beyond my control.

•  I understand that if I do not return to work on the date indicated above (or another date as specified by me and agreed to by the City), my employment may be terminated by the City as of the date my leave expires.

Employee Signature

Date

Supervisor Acknowledgement

Supervisor Name (Type or print):      

Supervisor Signature

Date