Statutory Leave Request 

 

Confidentiality Disclaimer:

 

The information provided by the employee on the Statutory Leave Request form is intended solely for need-to-know audiences who are reasonably expected to process and distribute sensitive medical information on behalf of building-specific employees. This information must not be shared with individuals outside of the Human Resources Department and other designated need-to-know audiences. These audiences include, but are not limited to: school principals, office managers, Human Resources staff, Payroll staff, and the employee's supervisor.

 

Additionally, employees who submit an application with American Fidelity may have information related to their Statutory Leave request shared with American Fidelity.

 

You may request that the information provided in this form be maintained exclusively within the Human Resources department by contacting HR directly. If you make this request, do not save or submit the form unless directed to do so by HR. Upon such a request, HR will take additional steps to restrict the sharing of this information, but may still be required to disclose general details to a limited group of need-to-know individuals in relation to specific accommodations, payroll considerations, or scheduling requests.

 

Certification Requirement

Medical certification is required for HR to properly designate your leave request(s) for your own, or a family member's, serious health condition. You are encouraged to submit this request even if you have not yet secured your medical certification.

 

A Medical Certification form is attached to your Frontline “Statutory Leave Request” form, and available upon request to HR or your Office Manager. Please provide the completed medical certification form to Human Resources within 15 calendar days of the date of your leave request. Contact Jessica Atherton, in writing, if you are unable to secure medical certification by the time you need to take time off due to a serious health condition.

 

Requests for foreseeable leave should be submitted at least 30 days in advance, even if you are unsure whether you qualify for FMLA or PLO. Leave related to pregnancy disability or a child’s serious health condition should also be communicated at least 30 days in advance, when practical.

 

If you are released to return to work earlier than your originally communicated return date, later than your originally communicated return date, or while taking prescription medication that may impact your ability to do your job safely, please ask your physician to complete a “Fitness for Duty” form before you return. This can be provided upon the request of HR, and found on attached to the “Statutory Leave Request” form in Frontline. This helps us identify and prepare for any accommodations your physician may recommend in advance.

 

Paid Medical Leave Insurance

 

All Roseburg Public Schools employees are eligible to apply for Paid Family Medical Leave Insurance (PFMLI). A response to the questions below is required so payroll can properly coordinate your accrued leave with your requested time off.

PFMLI applications must generally be submitted within 30 days of starting your leave. PFMLI only applies to full-day absences, and employees cannot receive PFMLI benefits during the same period they are eligible for Workers’ Compensation.

 

Employees are responsible for accurately recording or verifying with their office manager that their absences in Absence Management match any requested time off through American Fidelity. When requesting PFMLI benefits, you must report to American Fidelity your intermittent day(s), or the start of a consecutive leave period, within 30 days of the initial use and intermittent days thereafter to avoid a reduction in PFMLI benefits. Additionally, only days in which you intend to claim PFMLI may be entered as an unpaid status in Frontline if you choose not to utilize your accrued leave during your anticipated PFMLI period.

 

If you use PFMLI during a week that includes one or more holidays paid by Roseburg Public Schools, you may also receive payment from American Fidelity. However, any days paid through American Fidelity will count against your total PFMLI benefit period.

To avoid prematurely exhausting your PFMLI benefits, contact American Fidelity to determine the best way to coordinate your consecutive or intermittent leave period(s).

 

To avoid processing delays or a reduction in benefits, submit your PFMLI application before your leave begins, whenever possible. It is especially important to submit your leave request prior to the payroll cut-off date if you choose to go into an unpaid status with your employer. Payroll cutoff dates.

 

If you are submitting a PFMLI application, you will be asked whether you would like federal or state taxes withheld for certain types of leave. Please note that “Bonding” leave does not allow employees to opt in or out of tax withholding. Contact your tax advisor for guidance on how best to respond to these deduction questions.

 

You are encouraged to contact PERS with any questions about the implications, if any, to your retirement may be if you opt to go into an unpaid status with your employer. Find frequently asked questions regarding the coordination of accrued leave with Paid Leave Oregon.

 

Apply for PFMLI

 

Absence Reporting

Whether you intend to apply for PFMLI or not, you must follow your normal absence reporting procedure and keep your supervisor informed of any upcoming absences and necessary modifications at your earliest opportunity. Your absences should be recorded in advance whenever possible for appropriate coverage to be arranged.

 

What do I enter in Absence Management?

If using accrued leave, Sick Leave/Time should be used first before drawing on any other leave types. If you use a leave type other than "Sick" you must include the same note as you would for Sick Leave/Time (see below). When providing a general absence reason, it is not necessary to provide information about a specific diagnosis or procedure; see the chart below titled “General Absence Reasons” for a list of reasons that may qualify for one or more Statutorily protected leave types.

 

 

Absence Reason in Frontline Absence Management	Notes to Include to Administrator:
If you choose to use your accrued leave with PFMLI:	[Type "Family Leave + PFMLI" (+ general leave reason) in the notes section.]
Sick-> Self/Family
If you DO NOT intend to apply for PFMLI:	[Type "Family Leave" (+ general leave reason) in the notes section.]
Sick-> Self/Family
If you choose NOT to use your accrued leave during your anticipated PFMLI period:	[Type in a general leave reason and who your leave relates to in the notes section.]
Unpaid Status -> Paid Family Leave Request

 

 

If you are taking care of a family member during your requested leave period, please provide the relationship and the first name of the family member in the “Notes to Administrator” section.

 

If you have an insufficient accrued leave balance, you may use the "Unpaid Status" code(s) in Absence Management if you plan to apply for PFMLI. Contact your Office Manager or HR if at any time you are unsure how to enter your absences. 

 

***Under no circumstances should the "Activity" or "Dock Leave" absence codes be used for a medical or family leave request.***

 

 

General Absence Reasons (Examples)
Family / Personal Illness	Bereavement	Public Health Emergency	Safe Leave
Self-Care (Illness/Incapacity)	Attending the funeral or alternative to a funeral of a family member	Closure of business, or the school or place of care of your child, by order of a public official due to a public health emergency	Absences related to domestic violence, harassment, sexual assault, bias, or stalking:
Seeking Medical Diagnosis	Making arrangements necessitated by the death of the family member	Exclusion for the workplace required by the employer.	Seeking medical care, obtaining support services, consulting with an attorney, addressing legal matters, filing a police report, relocating to a new home, etc.
Care, or treatment of an illness, injury, or health condition	Grieving the death of the family Member	Wildfire Evacuation
To recover from, or seek treatment for, a health condition.

 

 

Am I responsible for securing a substitute if my position normally requires one?

 

You must communicate with your Office Manager and supervisor about the need to secure a substitute in your absence at your earliest opportunity. You are not required to find a substitute during a statutorily protected leave of absence. With that said, emergency substitute plans should be in place in case you do not have sufficient time to create them before taking leave. 

 

Your Office Manager should contact Edustaff at 877-974-6338 x1313 for long-term assignments. Additional requirements pertain to long-term substitutes subbing for a certified teacher.  

 

Leave Request Submission

 

Once your “Statutory Leave Request” form is signed and submitted, it is routed to Jessica Atherton (Ext 4009) in Human Resources and Payroll for processing. By signing the “Statutory Leave Request” form, you acknowledge that you have read and understood the information provided on the form, your absence reporting responsibilities, certification requirements, and the attached documents listed below:

 

• Workplace Accommodations Notice
• FMLA & OFLA 
• American Fidelity Paid Leave Oregon Brochure
• EEO (Equal Employment Opportunity) Poster
• Employee Eligibility, Rights, and Responsibilities
• Medical Certification Form
• Canopy EAP Benefits

 

Upon review of the information provided, you will be provided with specific information that relates to your statutory leave eligibility and designation. The Designation workflow is generally submitted once sufficient time has been provided to return any outstanding documentation requested for final determination and designation as to what, if any, leave options may be utilized or has been utilized during your requested leave period.

 

If you have any questions or concerns, contact Jessica Atherton at 541-440-4009 or jatherton@roseburg.k12.or.us to make an appointment to meet or discuss your leave request further.

 

Eligibility and Employee Rights & Responsibilities 

 

Section I describes what statutory leave type(s) you may be eligible for.

Section II indicates what certification is needed to approve your leave, if any.

Section III describes:

 

• coordination of your leave;
• what your responsibilities are to maintain, make changes, or add benefit coverage(s);
• who to contact to make your regularly occurring benefit premiums during your absence;
• what your return-to-work requirements are (if any);
• and how often you are expected to follow up with the HR department while on leave.
   

Section 1: Notice of Eligibility

 

To be eligible to take job-protected leave under the Family Medical Leave Act (FMLA), an employee must have worked for an employer for at least 12 months and meet the hours-of-service requirement in the 12 months preceding the leave. In general, to be eligible for job-protected leave under Oregon Family Medical Leave (OFLA), an employee must have worked an average of 25 hours per week for 180 days. To qualify for job-protected leave under Paid Leave Oregon (PLO) for Paid Family Medical Leave Insurance (PFMLI), the employee must have worked at least 90 consecutive days. PFMLI benefits may be paid to employees who have worked at least 30 days, but may not be eligible for job-protection benefits. Additionally, you may be protected under the ADA if reasonable accommodations are identified during the interactive ADA process. 

 

Section 2: Additional Information Needed

 

If you have not yet submitted the required certification, you must do so by the deadline listed on the Eligibility Rights & Responsibilities form provided by Human Resources—unless extraordinary circumstances prevent you from meeting this deadline.

 

If you believe you have already submitted the certification, but are later asked to provide it again, you must confirm with Human Resources that it was received. If possible, you should also request that they provide you with a copy if it does not present an economic hardship.

 

If your certification is being faxed to Human Resources, first confirm with the sending facility that the fax was successfully sent. This will help expedite the confirmation process.

 

If you are unable to meet the certification deadline, you must notify HR in writing before the deadline with an explanation. This notice is required unless you are physically or mentally incapacitated. If you are incapacitated, you must notify HR as soon as reasonably possible. In the absence of proper communication regarding your return-to-work status and adherence to communicated deadlines, they may be considered a failure to fulfill the duties of an employee and lead to disciplinary actions up to, and including, termination.

 

To prepare for unexpected situations, it is recommended that you designate a health-care power of attorney who can communicate on your behalf if needed. Resources for doing so are available through the Employee Assistance Plan (see the EAP brochure or contact HR for more information).

 

Certification Requirement

 

Medical certification is generally required to support a medical-related leave request. A form is attached to the “Statutory Leave Request” form and available upon the request of your Office Manager or HR.

 

If your leave is not medical in nature, access a full list of acceptable documentation examples.

 

Failure to provide complete and sufficient certification in a timely manner may result in the denial or revocation of any pending or previously tentatively approved leave of absence. It may also result in disciplinary action, up to and including termination. Repeated failure to provide requested information may be considered a failure to fulfill the duties of an employee.

 

Leave Types for a Family Member's Pregnancy Disability / Postpartum Recovery

 

If you do not anticipate being out for more than four days, or if you do not plan to participate in your family member’s prenatal or postnatal care and recovery, medical certification may not be required. However, if you intend to apply for PFMLI benefits, or use your accrued sick leave, absences of five or more days generally require medical certification from the pregnant or birthing parent's physician. The certification is used to support your leave as either a consecutive or intermittent basis.

 

Section 3: Notice of Rights & Responsibilities

 

Part A: Family Medical Leave Entitlement

 

You may be entitled to take job-protected leave for certain family and medical reasons under one or more of the following programs:

 

Family and Medical Leave Act (FMLA)

 

Under the FMLA, you may take up to 12 weeks of unpaid, job-protected leave in a 12-month period for:

• Your own serious health condition
• A serious health condition of a qualifying family member
• The birth, adoption, or foster care placement of a child
• Certain qualifying exigencies related to a military family member’s deployment

You may also be eligible for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered service member with a serious injury or illness (Military Caregiver Leave).

 

Eligibility Requirements:

• At least 12 months of employment
• At least 1,250 hours worked during the 12 months before your leave begins

Leave Measurement:

 

FMLA leave is measured over a 52-week period starting on the first day your approved leave begins

Please note: Based on your position, you may or may not be classified as a “key employee” under FMLA. While this does not affect your right to take FMLA leave, reinstatement to your position may not be guaranteed if doing so would result in substantial and grievous economic injury to the district.

 

Oregon Family Leave Act (OFLA)

 

Under the OFLA, you may take up to 12 weeks of unpaid, job-protected leave in a 12-month period for:

• Home care for a child with a serious or non-serious health condition for which you are unable to find alternative care for.
• Bereavement leave (up to 2 weeks per family member, limited to 4 weeks per leave year)
• Pregnancy disability (up to 12 weeks)

 

Bereavement leave must be used within 60 days of learning of the family member’s death. Combined, OFLA leave for home care of a child and bereavement cannot exceed 12 weeks.

 

Eligibility Requirements:

 

• At least 180 days of employment
• An average of 25 hours worked per week

 

Leave Measurement:

 

• OFLA leave is measured over a 52-week period starting on the Sunday before your leave begins

 

Paid Leave Oregon provides paid, job-protected leave for:

 

• Medical leave (your own serious health condition)
• Family leave (caring for a family member or bonding with a new child)
• Safe leave (related to domestic violence, harassment, stalking, or sexual assault)

 

Duration of Benefits:

 

• Up to 12 weeks of paid leave per benefit year
• Up to 14 weeks for pregnancy-related medical leave (e.g., prenatal care, pregnancy disability, postpartum recovery)

 

Eligibility Requirements:

 

• Earned at least $1,000 in wages in the year prior
• Employed for at least 30 days for wage benefits
• Employed for at least 90 days for wage benefits and job protection

 

Leave Measurement:

 

• PLO leave is measured over a 52-week period beginning on the Sunday before your leave begins
• Please note: PLO does not reduce your Oregon Military Family Leave Act protections provided under OFLA.

 

Sick Leave and Sick Time

 

All school employees are entitled to a minimum of 10 days of full-paid sick leave per school year, or one day per month employed, whichever is greater. Employees not covered by a collective bargaining agreement may accrue Sick Time at the rate defined by Oregon statute.

 

Sick Leave and Sick Time may be used for qualifying purposes as defined under federal and state law. If you have any questions about your leave options or responsibilities, please contact Human Resources at 541-440-4008. We are here to support you in navigating the leave process.

 

"Key" Employee Designation

 

If it is indicated below that you are a "key" employee as defined under the FMLA, your FMLA leave cannot be denied for this reason; however, we may not restore you to employment following FMLA leave if such restoration will cause substantial and grievous economic injury to us. 

 

Part B: Use of Accrued Leave and Paid Leave Eligibility

 

American Fidelity administers Paid Leave Oregon (PLO) benefits for our school district. If you apply, you may receive Paid Family and Medical Leave Insurance (PFMLI) payments to replace all or most of your wages during the approved paid leave period. To receive PFMLI benefits, you must apply for and be approved through American Fidelity.

 

Even if you do not request it, FMLA and OFLA allows the district to require you to use your available sick leave, vacation leave, or other paid leave during your FMLA and/or OFLA absence when you are either ineligible for PFMLI or choose not to apply. Please refer to the attached American Fidelity flyer to learn more about PFMLI. Apply online.

 

If you indicate that you intend to apply for PFMLI, you will not be required to use your accrued leave while a PFMLI decision is pending. You will have the ability to place yourself in an “unpaid” status for the day(s) you anticipate receiving PFMLI benefits and do not wish to use accrued leave. However, if your application is not submitted in a timely manner- or is denied, you must use your accrued leave in the order otherwise required in the absence of a PFMLI claim.

 

Concurrent leave use means the absence will count against multiple leave types simultaneously. PLO is intended to run concurrently with FMLA, but not with OFLA. If you do not meet the requirements for PLO, you may still be entitled to use available unpaid FMLA and/or OFLA leave during the applicable 12-month period. Employees are required to use their accrued leave during an otherwise unpaid FMLA and/or OFLA leave period in the absence of an approved PFMLI claim.

 

• Leave that qualifies for both FMLA and OFLA, but not PLO, will run concurrently.
• Leave that qualifies for both PLO and FMLA will also run concurrently.

 

Leave Communication Responsibilities:

 

If you do not make a leave coordination selection on your leave request form, you will be paid according to the information you entered in Frontline or submitted to your Absence Management Campus User. All absence requests should be entered by the employee into Absence Management, or communicated to the appropriate Campus User as soon as possible if unable to submit themselves.

 

You must keep your supervisor informed of your leave request, and any changes to that request, that you provide to your Campus User (Office Manager or Assistant) and/or the Human Resources Department. HR will designate your leave in Absence Management after all relevant information is collected and reviewed. A Designation Notice is also provided in the next section during the initial review of materials and information provided during the certification request period. If the certification provided is missing or insufficient, you will be provided with a second Designation Notice at the conclusion of the next certification request period.

 

You may contact HR and your union representative if at any time you would like assistance navigating the certification request process or the ADA interactive process.

 

 

Classified Staff:	Certified Staff:
Steve Sears Field Representative	David Morrocco REA President
steve@osea.org	dmorrocco@roseburg.k12.or.us
C: 503-559-0931

 

 

 

 

 

 

 

Part C: Maintaining Health Benefits

Your health benefits and job protections under OFLA, FMLA, and PLO must be maintained during any period of paid or unpaid leave, under the same conditions as if you had continued working. Upon return from leave, you must be reinstated to the same position—or in some cases, an equivalent position—with the same pay, benefits, and terms and conditions of employment.

 

If you do not return to work following your OFLA/FMLA/PLO leave for a reason other than (1) the continuation, recurrence, or onset of a serious health condition that would entitle you to additional leave as supported by updated medical certification, or (2) other circumstances beyond your control, you may be required to reimburse the district for health insurance premiums paid on your behalf during your anticipated leave period.

 

If you normally pay a portion of your health insurance premiums or other deductions, these payments will continue during your leave. If any portion of your leave will be unpaid by Roseburg Public Schools, you must contact our Payroll Specialist, Summer Kendall, at 541-440-4025 to arrange for payment of premiums not covered by payroll deductions. As a reminder, employees who claim PFMLI benefits are paid by American Fidelity, and not their employer.

 

To ensure uninterrupted benefits during your absence, you must submit any payments not satisfied by your accrued leave to the Roseburg Public Schools Business Office by the first business day of each month.

 

If the district pays any portion of your share of health or other insurance premiums while you are on OFLA/FMLA/PLO leave, the district may deduct up to 10% of your gross pay from each paycheck after your return to work until the amount is fully repaid.

 

You have a 30-day grace period to make premium payments. If payment is not received within that period, your group health insurance may be canceled—provided the district gives written notice at least 15 days before coverage will lapse. Alternatively, the district may pay your share of premiums (as allowed under board policy or a negotiated agreement) and recover those costs upon your return.

 

If you do not return to work following the conclusion of your OFLA/FMLA/PLO leave, and the district has paid your share of benefit premiums, you are responsible for reimbursing the district for the amount paid on your behalf.

 

If you do not return to work on your expected return date, and the district does not receive updated medical certification within two days of your doctor releasing you or ending your leave on a medical certification form, your benefits may be terminated. Coverage will end on the first day of the month following any unexcused absence after your approved leave period.

 

Part D: Other Employee Benefits

 

Upon your return from OFLA/FMLA/PLO leave, your employee benefits—such as pension, life insurance, disability insurance, and others—will be resumed in the same manner and at the same levels as when your leave began. If the district covered your premiums for these benefits during your leave, you will not be expected to reimburse the district upon your return to work.

 

To make arrangements to continue your employee benefits while on leave, please contact Payroll Specialist, Summer Kendall, at 541-440-4025.

 

Part E: Return-to-Work Requirements

 

At the conclusion of your certified OFLA/FMLA/PLO leave, you must generally be reinstated to the same or an equivalent job with the same pay, benefits, and working conditions. An equivalent position is virtually identical to your original position in terms of pay, duties, benefits, and status.

 

However, you do not have return-to-work rights if you require leave beyond the limits provided under OFLA, FMLA, PLO, or Sick Leave provisions. In such cases, you may refer to your collective bargaining agreement (CBA) for options to extend your leave through additional paid or unpaid leave options.

If you are unable to return to work as expected, you must provide written updates to Human Resources at least weekly regarding your medical certification and return status. In some cases, you may be asked to provide more frequent updates pending the receipt of necessary information to designate your leave appropriately and promptly.

If your phone number or mailing address has changed since submitting your initial leave request, notify Human Resources in writing as soon as possible.

 

Part F: Other Requirements While on Leave

 

While on leave, you are required to provide weekly status updates to Human Resources Specialist Jessica Atherton, unless you are within a period of approved and certified leave. You must also update your supervisor with any updates as well. 

You will receive a separate communication designating your leave as “approved,” “tentatively approved,” or “unapproved” once sufficient information is received and processed.

If your circumstances change and you can return to work earlier than expected, you must notify Human Resources at least two workdays in advance of your intended return date.

 

Part G: Safe Leave – Domestic Violence Protections

 

If you are at risk of or have experienced domestic violence, harassment, sexual assault, or stalking—or are the parent or guardian of a victim—you may request reasonable changes to your working conditions to support your safety.

 

In addition, you are entitled to protected but unpaid leave (absent undue hardship on the employer) for purposes such as:

 

• Seeking legal or law enforcement assistance
• Obtaining medical or mental health care
• Relocating or making safety-related housing changes
• Addressing other necessary safety concerns

If you need leave for any reason described in Part G, please submit your request directly to the Human Resources office if you have not already done so.

 

Designation Notice:

 

This notice provides you with additional information regarding the status of your leave request based on the most recent information provided on your statutory leave request form, and communications received via email, telephone, and in-person (if applicable). If your request period(s) need to be altered in any way, please submit a request in writing at your earliest opportunity. 

 

Certification Requirement

 

Your certification helps us determine which leave type(s), if any, apply to your request. A certification is considered "insufficient" if the information provided is vague, unclear, ambiguous, incomplete, or non-responsive. If complete and sufficient documentation is not submitted in a timely manner, your leave may be denied or its start date delayed, even if it was tentatively approved pending receipt of certification.

 

If you choose to apply for Paid Family and Medical Leave Insurance (PFMLI), you must contact American Fidelity directly at 1-800-662-1113 to confirm they have received all necessary documentation. To help expedite your claim, provide American Fidelity with a copy of any certification you submitted to HR.

 

If requested, you must provide sufficient certification no later than the date indicated below. If doing so is not practical under the circumstances, despite your diligent, good-faith efforts, you must notify HR prior to the communicated deadline.

 

If the summarized election choices on the completed PDF version of this form are not what you intended, please contact Jessica Atherton in the Human Resources department at your earliest opportunity. Below is your leave calendar based on the leave request you submitted and in consideration of any other applicable leave utilized up to your most recent leave request date. The PFMLI calendar, if applicable, is only an estimate, as American Fidelity determines the final details of your leave calendar.