1910F2 - EFMLA Employee Request Form

Last Updated: 11/3/2020 8:36 PM

Belgrade School District - Employee Request Form - Emergency FMLA 1910F2

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Employees may be entitled to Emergency FMLA (EFMLA) in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards. Employees can complete this form and submit it or any questions to the H.R. department at the district's administration building.

Section 1

  • Employee Name
  • Mailing Address
  • E-Mail
  • Home Phone Number
  • Alternate Phone Number
  • Employment Start Date (Employees must  have worked for School District for 30 days to be eligible for EFMLA)
  • Anticipated Begin Date of Leave
  • Expected Return to work Date

Section 2


Employees satisfying the standards noted below are eligible for 12 weeks* of leave. The first two weeks of the leave are unpaid unless the employee selects available options in the next box. The remaining 10 weeks of leave are paid at 2/3 of the employee's regular compensation rate unless other options are selected on this form. Please select the applicable reason and follow the applicable instructions.

  • I am unable to work or telework because I need to care for my child under age 18 because my child's elementary or secondary school, childcare provider, or child's place of care has been closed or is unavailable due to a public health emergency. During this period of unavailability or closure, I represent that no other person will be providing care for my child during the period for which I am receiving EFMLA.
    • Name(s) and Age(s) of Child or Children:
      • If the age of one or more of the children is between 14 and 18, the following special circumstances exist requiring me to care for the child during daylight hours:

Please attach notice or documentation related to the unavailability of the school, daycare, place of care or person providing care to the child. The School District reserves the right to request confirmation regarding the nature of the closure or unavailability.

* An employee who qualifies for and utilizes the Emergency Paid Sick Leave provisions of the FFCRA, is entitled to an additional 10 weeks of Emergency FMLA. Direct questions about or requests for this leave to the staff member noted above.

Section 3


In accordance with the FFCRA, the first ten days of EFMLA is unpaid, however you may be eligible to use Emergency Paid Sick Leave provided through the FFCRA to cover this period at 2/3 of full pay. In the event you have already used Emergency Paid Sick Leave, you are permitted to use available District-provided paid leave to cover this period at full pay. Please indicate if you would like to use paid leave during the first 10 days of your absence and how many hours you plan to use. Requested leave is subject to availability based on confirmation by the School District. If requesting Emergency Paid Sick Leave, please complete and submit an Emergency Paid Sick Leave form.

  • Vacation: ____Hours
  • Sick Leave: ____Hours
  • Personal: ____Hours
  • FFCRA: ____Hours


After completing the first ten days of EFMLA, an employee may choose to take 10 weeks of continuous leave under EFMLA
for the reason indicated above. Continuous leave means the employee will not complete any District duties during this period
but will be compensated based on the options selected above.

An employee may also choose to take 10 weeks of intermittent leave. Intermittent leave means an employee will complete some District duties on a modified schedule as approved by the employee's supervisor. When using intermittent leave, the employee will receive full regular pay for hours worked and 2/3 of regular pay during periods on EFMLA unless supplemented in a manner noted above.

I am requesting (choose one):

  • Continuous Leave
  •  Intermittent Leave

If your need for leave is intermittent, please describe the requested schedule for your intermittent leave:

Section 4


I certify that the above information is accurate and complete. I understand that if I fail to report for work on or before the scheduled return date indicated above or fail to honor the intermittent EFMLA schedule I may be subject to discipline in accordance with School District Policy.

  • Employee Signature
  • Date

Section 5


  • Request Received By
  • Date
  • Leave Approved By
  • Date
  • Period of Leave
  • Intermittent Leave Schedule if Applicable
  • Duration and Type of Substituted Leave for First Ten Days Approved
  • Duration and Type of Supplemental Leave to Earn Full Pay Approved

The School District will retain all records related to this leave request for at least 4 years for auditing purposes.

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