Request for Leave - Classified

Complete Sections A (if required by your department) and B of this form in accordance with the Collective Bargaining Agreement whenever you are requesting leave.

Name: _____________________________ UO ID__________________ Date: _____________

I hereby request leave from _________________ (date/time) to __________________ (date/time)

A. WHAT TYPE OF LEAVE ARE YOU REQUESTING? (complete all that apply)

APPROVED: _____________ DENIED: _______________ Reason for denial (circle one):

(1) Did not meet contractual requirements for advance notice.

(2) Workload too great.

(3) Other staff members have already requested time off.

(4) Other: ___________________________________.

B. WHAT IS THE REASON FOR THE LEAVE YOU ARE REQUESTING? - (Check all that apply)

[ ] Vacation [ ] Military Leave [ ] Jury Duty [ ] Personal Business

[ ] Health Condition (check one of the following) [ ] Reason other than those listed:

1. [ ] Your minor illness or [ ] your immediate family/household's minor illness (minor illness does not meet the definition of serious health condition shown on back.)

OHR APPROVAL FOR FMLA/OREGON LEAVE
[ ] Approved;
[ ] FMLA and OFLA (Subject to receipt of physician's certification form, if required for this leave)
[ ] OFLA ONLY (Subject to receipt of physician's certification form, if required for this leave)
[ ] Not approved: Reason ____________________________________.

* NOTE to SUPERVISOR: If FMLA/OFLA leave is requested, you must send a copy of this form to Human Resources, Benefits Section, for approval and federal recordkeeping requirements.

Family Medical & Leave Act (FMLA)
Maximum Leave: 12 weeks in a 12-month period (12 consecutive weeks for foster care, adoption, or care for a newborn child unless intermittent or reduced hours leave is approved by the supervisor).

Eligibility : You must have at least 12 months of employment with the State of Oregon (need not be consecutive service time); AND, during your last 12 months of employment prior to the date leave commences, you must have worked at least 1250 hours.

Definitions :
A "Serious Health Condition" means an illness, injury, impairment, or physical or mental condition that involves one of the following: (Conditions that do not meet definition unless complications arise are: common cold, flu, ear aches, upset stomachs, minor ulcers, and headaches other than migraines).

1. Hospital Care
Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity of subsequent treatment in connection with or consequent to such inpatient care.

2. Absence Plus Treatment
(a) A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves:
(1) Treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or
(2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.

3. Pregnancy
Any period of incapacity due to pregnancy, or for prenatal care.

4. Chronic Conditions Requiring Treatments
A chronic condition which
(1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under direct supervision of a health care provider;
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).

5. Permanent Long-term Conditions Requiring Supervision
A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimer's, a severe stroke, or the terminal stages of a disease.

6. Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy) kidney disease (dialysis).

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Oregon Family Leave Act (OFLA)
Maximum Leave: 12 weeks in a 12-month period. (Some exceptions apply.)

Eligibility : For OFLA leaves due to serious health conditions or pregnancy, you must have at least 180 calendar days of consecutive UO employment and have worked an average of 25 or more hours per week during the prior 180 days. There is no hours test for OFLA leaves to care for a newborn child or for adoption.

If eligible only for OFLA, the definition of a serious health condition closely tracks the FMLA serious health condition definitions listed above. OFLA also includes a terminal illness or imminent danger of death and constant or continuing care.
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If leave qualifies under both the FMLA and OFLA, or the FMLA and contractual benefit provisions, its use is counted against both entitlements. Any FMLA leave will also count as OFLA leave.