Pearland ISD Leave Request Form

 
 
  

 
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1.
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2.
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Name   
   
3.
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4.
*
 
   
5.
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6.
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Temporary Disability applicants may only select reason f.
 
   
7.
 
   
 

Required Documentation:

Leave Reason 6a: Verification of Birth
Leave Reason 6b: Adoption/Foster Care documents
Leave Reason 6c-f: Medical Certification*
*Form will be provided if eligible for leave
   
8.
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  Select Date
mm/dd/yyyy
   
9.
  Select Date
mm/dd/yyyy
   
10.
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11.
 
   
12.
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Choose any that apply    
   
13.
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District Email 
Personal Email 
Mailing Address 
   
14.
*
Example: 999-999-9999
 
   
 

District Policy and Information regarding Leaves and Absences:
Leaves and Absences DEC Local Policy

Leaves and Absences DEC Legal Policy

FMLA General Information

TDL General Information

   
  I hereby agree that while I am on leave, I will continue to pay my share of health insurance premiums, unless I elect to discontinue such coverage. I also agree that if I fail to return to work at the end of the leave period, I will reimburse the District for the cost of health benefits provided during my leave, unless I fail to return to work because of the continuation, recurrence, or onset of a serious health condition, or because of other circumstances beyond my control. If I am unable to return to work because of a serious health condition, I will provide medical certification from the appropriate health care provider stating that I am unable to perform the functions of my position on the date that my leave expired or that I am needed to care for my spouse/parent/child because he/she has a serious health condition on the date that my leave expired. I understand that I may not be permitted to resume my position with the District until I provide medical certification, as appropriate.
   
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