TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

LEAVE REQUEST FORM

Please complete the appropriate section of this checklist. This form should be returned to Human Resource Management by August 19, 2020 via email at: covidhealthdocs@teaneckschools.org. PLEASE NOTE ALL LEAVE REQUESTS REQUIRE MEDICAL CERTIFICATION.

Employee Name	________________________	School/Dept.	______________________________

Contact Information: Email ____________________

Phone ____________________

____ I am seeking a leave for the birth of my child or to care for my newborn child.

Complete and submit the following form. https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf

____ I am seeking leave for the placement of a child with me for adoption or foster care.

Complete and submit the following form. https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf

_____ I am seeking a leave due to a qualifying exigency because a family member is on or has been called to covered active duty or to care for a family member who is a current member of the Armed Forces who is undergoing medical treatment. Relationship of family member to you: _____________________

Complete and submit the following form. https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf

COVID-19 Related Leave Requests:

____ I am seeking a leave for my own health condition including advisement by my healthcare provider or pursuant to a federal, state, or local public health authority order to quarantine or I am experiencing symptoms of COVID-19 and am seeking a medical diagnosis.

Complete and submit the following form. https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-E.pdf

____ I am seeking a leave due to childcare needs during the COVID-19 pandemic (documentation required). I am seeking the following schedule for childcare purposes:____________________________________________________________

____ I am seeking a leave to care for a covered family member with a serious health condition.

Relationship of family member to you:_____________________________

Complete and submit the following form. https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf

____ I am seeking a leave to care for a loved one who is in coronavirus quarantine, is coronavirus positive or symptomatic.

Complete and submit the following form. https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf

____ I am seeking a leave to self-quarantine for 14 days commencing ________ through _________ due to travel outside the State of New Jersey or other reasons NOT certified by healthcare providers or public health authorities.

I am seeking a leave for the period _____________ to __________________________.

If intermittent or reduced-leave schedule is being requested, please explain why it is needed and the proposed leave schedule:

______________________________________________________________________________

I certify that the above information is true and correct to the best of my knowledge:

Employee Signature________________________________________ Date: ______________

Determination of eligibility for leave, and/or additional documentation or clarification of documentation, may be required prior to making a final leave determination.

For Employer Use Only

Documentation Received	____________________

Date

Leave Request Approved (See separate Approval Form) ________________________

Date

Leave Request Denied (See separate Denial Form ) ______________________________

Date

Leave Request Approved for the Period ____________________________________________

Dates

Return to Work Criteria

The New Jersey Restart and Recovery Plan for Education, “The Road Back” states that in all stages and phases of pandemic response and recovery, schools must comply with Center for Disease Control (CD), state and local guidelines for health and safety. Please consult the following link for the NJDOH/CDC guidelines for returning to work.

https://www.nj.gov/health/cd/documents/topics/NCOV/COVID-QuickRef_Discont_Isolation_and_TBP.pdf