Leave Requests - Family Medical Leave Act (FMLA)

About

We understand that sometimes life requires time away from work for medical, family, and other reasons. This section provides information on the types of leaves, application process, and important policy reminders on taking leave at the District. Our goal is to make the process simple and supportive, while maintaining compliance with relevant laws and District policies. For more information on leave please be sure to review Board Policy 3430.01 - Family and Medical Leave of Absence (FMLA) and Board Policy 3231.01 - Outside Employment.

Employees must fill out the Leave Request Form and the associated certification form below and submit to the Employee Health Services team at the email or fax number below. Completed medical and leave-related forms must be submitted directly to Employee Health Services only to protect employee information and privacy.

Do not submit medical forms to supervisors, managers, or clerical staff. These individuals are not authorized to receive or store confidential medical information. If you have questions about what documentation is required or how to submit your forms, please contact the EHS team.

For any questions related to leaves of absence, please don't hesitate to reach out to the team at dps.ehs@detroitk12.org or (313)-263-2891. Our fax information is (313)-748-6119.

Required Forms

Leave Request Form

Request for FMLA (Family Medical Leave Act) Leave should be submitted no less than 30 days prior to the need for leave for a known medical condition or as soon as practicable if unknown. The form should be completed for your own or a covered family members serious health condition and faxed to (313) 748-6119. Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has also been received and reviewed.

Leave Request Form

Certification of Health Care Provider - Employee

This form is to be completed by your physician and submitted within 15 calendar days of your leave request form if you are requesting leave for yourself. Your physician should fax the fully completed form to (313) 748-6119. Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has been received and reviewed.

Employee Certification of Health Care Provider Form

Certification of Health Care Provider - Family Member

This form is to be completed by your covered family member's physician and submitted within 15 calendar days of your leave request form. Your physician should fax the fully completed form to (313) 748-6119. Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has been received and reviewed.

Please note, a separate form is required for each covered family member, they should not be noted on the same form.

Family Member Certification of Health Care Provider Form

Certification of Qualifying Exigency for Military Family Leave

A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a military member’s covered active duty or call to covered active-duty status. On the form, please check one of the options and be sure to attach the indicated document to support that the military member is on covered active duty or called to covered active-duty status.

Certification of Qualifying Exigency for Military Family Leave Form

Certification for Serious Injury or Illness of a Current Service Member -- For Military Leave

Section II is to be completed by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care provider; (3) a DOD non-network TRICARE authorized private health care provider; or (4) a health care provider as defined in 29 CFR 825.125.

Certification for Serious Injury or Illness of a Current Service Member - For Military Leave Form

Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave

The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. 2613, 2614(c)(3). Failure to do so may result in a denial of an employee’s FMLA request.

SECTION II: For completion by: (1) a United States Department of Defense (“DOD”) health care provider; (2) a United States Department of Veterans Affairs (“VA”) health care provider; (3) a DOD TRICARE network authorized private health care provider; (4) a DOD non-network TRICARE authorized private health care provider; or (5) a health care provider as defined in 29 CFR 825.125.

Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave Form

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