Human Resources

Pritnable FMLA Application

Application for Family or Medical Leave

Employee Name:

Address:

School/Location/Department:

FMLA Start Date:

Expected Date to Return to Work:

Reason for Leave (explain):

NOTE: A leave requested based on an employee's serious health condition or the serious health condition of an employee's spouse, child or parent must be accompanied by a verifying medical certification from a physician.

I hereby authorize my employer, the Tooele County School District, to contact my Physician to verify the reason for my requested leave or any other information concerning my requested family and medical leave.

Physician name:

Telephone:

I understand that failure to return to work at the end of my leave period may be treated as a resignation unless an extension has been agreed upon and approved in writing by my employer. If I am able to elect not to return to work, I will be required to reimburse health plan payments made by the Tooele County School District.

Employee's Signature:

Date:

This section is to be completed by the School/Location/Department.

Supervisor Approval:

Date:

HR Director Approval:

Date:

Printable FMLA Medical Certification Statement

Medical Certification Statement

To be completed by Health Care Provider

Employee Name:

Address:

Date Condition Began:

Date Condition Ended (or is expected to end):

Medical Facts Regarding Condition:

Explanation of extent to which employee is unable to perform the functions of his/her job:

Health Care Provider Signature:

Date:

Telephone:

Medical release to be completed by employee:

I authorize the release of my personal medical information pertinent to the granting of FMLA leave.

Employee Signature:

Date:

Printable FMLA Form WH-380-E

Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act

U.S. Department of Labor Wage and Hour Division

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.

OMB Control Number: 1235-0003 Expires: 6/30/2023

The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee's health care provider. 29 U.S.C. §§ 2613, 2614(c)(3); 29 C.F.R. § 825.305. The employer must give the employee at least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient medical certification, his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information about the FMLA may be found on the WHD website at www.dol.gov/agencies/whd/fmla (dol.gov in Bing).

SECTION I – EMPLOYER

Either the employee or the employer may complete Section I. While use of this form is optional, this form asks the health care provider for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R. § 825.306. You may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306–825.308. Additionally, you may not request a certification for FMLA leave to bond with a healthy newborn child or a child placed for adoption or foster care.

Employers must generally maintain records and documents relating to medical information, medical certifications, recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.

(1) Employee name: First / Middle / Last

(2) Employer name: Date (mm/dd/yyyy) (List date certification requested)

(3) The medical certification must be returned by (mm/dd/yyyy) (Must allow at least 15 calendar days from the date requested, unless it is not feasible despite the employee's diligent, good faith efforts.)

(4) Employee’s job title: Job description ☐ is / ☐ is not attached.

Employee’s regular work schedule:

Statement of the employee’s essential job functions: (The essential functions of the employee’s position are determined with reference to the position the employee held at the time the employee notified the employer of the need for leave or the leave started, whichever is earlier.)

SECTION II – HEALTH CARE PROVIDER

Please provide your contact information, complete all relevant parts of this Section, and sign the form. Your patient has requested leave under the FMLA. The FMLA allows an employer to require that the employee submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to the serious health condition of the employee.

For FMLA purposes, a “serious health condition” means an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider. For more information about the definitions of a serious health condition under the FMLA, see the chart on page 4.

You may, but are not required to, provide other appropriate medical facts including symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment. Please note that some state or local laws may not allow disclosure of private medical information about the patient’s serious health condition, such as providing the diagnosis and/or course of treatment.

Employee Name:

Health Care Provider’s name (Print):

Health Care Provider’s business address:

Type of practice / Medical specialty:

Telephone: Fax: E-mail:

PART A: Medical Information

Limit your response to the medical condition(s) for which the employee is seeking FMLA leave. Your answers should be your best estimate based upon your medical knowledge, experience, and examination of the patient.

(1) Approximate date the condition started or will start (mm/dd/yyyy):

(2) Best estimate of how long the condition lasted or will last:

(3) Check applicable boxes (leave details to be provided in Part B):

• ☐ Inpatient Care

• ☐ Incapacity plus Treatment

• ☐ Pregnancy

• ☐ Chronic Conditions

• ☐ Permanent or Long-Term Conditions

• ☐ Conditions requiring Multiple Treatments

• ☐ None of the above

(4) Other appropriate medical facts (e.g., use of nebulizer, dialysis):

PART B: Amount of Leave Needed

(5) Planned medical treatments (dates):

(6) Referrals to other providers: Nature of treatments, beginning and end dates, duration:

(7) Reduced schedule needed: From (mm/dd/yyyy) to (mm/dd/yyyy): Employee able to work (e.g., 5 hours/day, up to 25 hours/week):

(8) Continuous period of incapacity: Beginning date and end date:

(9) Intermittent absences: Estimated frequency and duration over next 6 months:

PART C: Essential Job Functions

(10) Due to the condition, the employee: ☐ was not able / ☐ is not able / ☐ will not be able to perform one or more essential job functions. Identify at least one essential job function the employee cannot perform:

Signature of Health Care Provider Date (mm/dd/yyyy)

Definitions of a Serious Health Condition

Includes:

• Inpatient care

• Incapacity plus treatment

• Pregnancy

• Chronic conditions

• Permanent or long-term conditions

• Conditions requiring multiple treatments

Paperwork Reduction Act Notice

Employers must retain a copy for three years. Estimated completion time: 15 minutes.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT.

Policy 4005

• Position needs are evaluated to help ensure more ideal class sizes.
• Job descriptions are created and re-evaluated as needed to help provide the best candidates.
• Recruitment activities occur at vetted sources for educators.
• Qualifications and references are reviewed for applicability.
• Screening committees are utilized to help select the best candidate for the position.
• Committee applicant selections are approved through the Human Resources department.
• Final employee approval goes through the authority of the Board of Education.

Policy 4006

• Background checks through the Bureau of Criminal Identification are performed on each prospective employee, contact employee, and qualifying volunteer prior to employment or service in the district.
  • FBI Rap Backs (Record of Arrest and Prosecution Backgrounds )are automatically conducted every five years.
  • If someone gets arrested, we are notified.
• These checks are comprehensive and thorough. Important details that are considered include:
  • Any convictions, including pleas in abeyance
  • Any matters involving a felony
  • Any matters alleging sexual or drug offenses
  • Offense against the person under Title 76, Chapter 5
  • Class A misdemeanor property offense within the prior three years
  • Any type of criminal offense, if more than one offense of the same type, within the prior eight years
• Employees must report any arrest, citation, or charge within 48 hours for any of the following alleged offenses:
  • Any matters involving:
    • Sex offenses, drug offenses, alcohol offenses
    • Title 76, Chapter 5
    • Any alleged crime of domestic violence
    • Vehicle code violations for those who drive as part of their employment

Policy 4011

• Employees are required to complete numerous training courses and have the highest expectations.
  • Employees are expected to know and adhere to district policies.
  • Employees complete Safe Schools training. Some of these topics include:
  • Student data privacy/FERPA
  • Fire extinguisher
  • PPE and bloodborne pathogens
  • Testing ethics
  • School finances and fees
  • Reporting requirements for student safety
  • Policy review, including scope of employment, bullying, abusive conduct, hazing, cyberbullying, and  student travel
  • Suicide prevention
  • Sexual harassment
  • Seizures
  • Child abuse
  • Human trafficking
  • Head injuries/concussion
  • Student Constitutional Rights

 

• Employees receive performance evaluations with corrective measures as needed
• Employees found to be in violation of policy/procedure are appropriately disciplined
• Provisional employees not meeting the expectations in other areas can be non-renewed
• Employees receive ongoing training through numerous venues and, in many cases, have the help of fantastic mentors to guide them.

 

Licensing Structure

Licensing is like a tree. The License is the trunk, the license area is the branch(es), and endorsements are the leaves. An educator can only hold 1 license, but can have multiple license areas, and many endorsements.

Example: Professionally licensed teacher, in the secondary area, who holds a math endorsement and a science endorsement.

I want to teach in Tooele School District. How do I get a teaching license if I did not graduate with a degree in education?

TCSD’s APPEL Program will provide the experiences, coursework, and support for the educator to earn a professional license in Elementary, Secondary, or CTE areas. Educators teach in the content area while working through the APPEL program.

*Please note: the Special Education license area is
not part of the TCSD APPEL program.

Steps

• Earn an Associate Educator License from the Utah State Board of Ed. (USBE). You must have a minimum of a university bachelor’s degree or industry certification (CTE only) in a specific area to be eligible for an Associate Educator License (AEL).
• Apply and be hired as a teacher of record at a TCSD school. Upload a copy of your AEL in job applications. Explore current job opportunities on our Applitrack site.
• Once you are hired, you will be accepted into TCSD’s APPEL program. After a transcript review, you will have an initial consultation with the APPEL director to review all program expectations and licensure requirements.
• Work for up to 3 years (on AEL) while completing all USBE professional licensure requirements including pedagogy and content competencies, clinical experiences, and assessments.
• Upon completion of all licensing requirements, candidates will be recommended to USBE for professional licensure.
• Continue working in TCSD with a professional license (renew every 5 years).

TCSD Partners with SLCC’s ‘Transition to Teaching’ program as well as SUU APPEL Courses to meet pedagogy course requirements.

  For more information, contact Krystal White:
  kwhite@tooeleschools.org.

Professional licenses expire every 5 years. Licensing renewals can be done as soon as January 1st of the expiration year.

What You Need to Renew

• Renewal Guide
• 100 clock hours of Renewal Activities
  • Check your MIDAS account for re-licensure hours
  • Professional Learning such as coursework, conferences, district training, mentoring, coaching, institutes, etc.
  • Educator Collaboration such as PLCs, data dives/analysis, and team collaboration
  • Professional Service such as local/state/national government or association leadership
  • Alternate Learning Opportunities

*Note these are actual clock hours spent on activities. The old point system has been retired. If you have college or USBE credits, you translate that into how many clock hours you spent on that activity or class.

• Complete all checklist items on USIMS.

What If I Had a License, But It Expired Years Ago?

• Use the same Renewal Guide. However, you will follow the instructions for a “returning educator.”

• Most Questions can be answered by visiting USBE’s Licensing webpage.

• What is an associate educator license?
  • An associate educator license (AEL) is a temporary license awarded by the Utah State Board of Education. This 3-year temporary license allows a candidate to teach while completing an educator preparation program. Bachelor‘s degree is required for all license areas except CTE.
• Once I have obtained an AEL, what comes next?
  • After obtaining an AEL, candidates must complete an educator prep program to become professionally licensed. USBE does not award initial professional licenses without an educator prep program’s recommendation (such as a university program or a district’s APPEL program.) Candidates must complete all professional requirements within 3 years.
• I am in a university educator program, can I start teaching now?
  • If you are enrolled in a university program to obtain both a bachelor’s degree and a teaching license, you can begin teaching when all coursework, except student teaching, is complete.
• I have a professional license from another jurisdiction, how do I get a Utah license?
  • Out of State and International educators must apply to USBE for a License Equivalency Review
• I want to become a special education teacher, how do I get that license?
  • To become a SPED teacher, you must first get an Associate License specifically for SPED. A bachelor’s degree is required and you must be enrolled in an educator prep program through USBE or a university. It is illegal for TCSD to employ any educator in a SPED position without a state-issued license (AEL or Professional). This applies to any position that falls under SPED such as preschool SPED, SLT, SLP, Psychologists, etc. You can find the SPED AEL application here.
• What is an endorsement?
  • An endorsement is a credential in a specific subject or field. An educator can apply for as many endorsements as they like. Secondary teachers must have at least 1 endorsement and are only qualified to teach the subjects in which they hold an endorsement. The Elementary license area does not require an endorsement. However, there are several they can add to specialize their license as well.
• How do I get my fingerprints and background check done... do I have to?
  • TCSD offers fingerprinting for educators and volunteers. Please call and set an appointment 435-833-1900. Fees may apply. Background checks done by other employers or state/federal agencies cannot be shared with USBE and may not meet USBE requirements.
• I hold a teaching license in elementary, can I teach secondary?  

  • Professionally licensed teachers can add an area (such as secondary) to their license by working with their APPEL director to earn the appropriate endorsement and demonstrate competency in that area. 

• Additional Links:
  MIDAS
  CACTUS
  USIMS
  USBE Frequently Asked Questions 
  License Renewals