Leave Request

Reason for Leave request:

You will be notified via email of what leave options you are eligible for (i.e. FMLA, TDL, etc.), along with any required documentation need. Some required documents will have to be returned within a specific timeframe.

Please review all documents received by the Benefits Team, as well as, and the employee handbook and board policy on the district website or the Benefits Page under Leaves, of the Pearland ISD website, noting your rights, deadlines, and if applicable, restrictions.

Order of Leave

If you do not select a leave choice, the following order will be selected for you:

Available Compensatory Time will be used prior to your selections below.

Nonduty days are unpaid and cannot be used for a leave of absence. Flex days cannot be used. See the Pearland ISD employee handbook for more information.

State Leave
Local Leave
Vacation

First Choice:

Second Choice:

Third Choice:

Contact Information

Namerequired

First Name

Middle (optional)

Last Name

Employee ID Numberrequired

Positionrequired

Work Location:required

Date on which you wish leave to start:required

Must contain a date in MM/DD/YYYY format

Date of anticipated return to work if known:

Must contain a date in MM/DD/YYYY format

Are you requesting leave on a full-time or intermittent basis?required

If intermittent, please give schedule of when you anticipate you will be unavailable for work.

Best way to Contact you during your leave of absence?requiredChoose any that apply

District Email

Personal Email

Phone Call

Choose any that apply

Would you like to setup a meeting with a Benefits Team member to discuss your leave options?required

Yes

No

How would you like to meet with the Benefits Teamrequired

Meet In-Person Onsite at Campus/Department

Meet In-Person at the ESC

Meet Virtually via Teams

By Phone

Inquiry:

Please enter any questions you would like to discuss during the meeting.

Contact Information:

Provide contact information below:

District Email:

Personal Email:

Mailing Address:

Phone Number:

Example: 999-999-9999

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message (our message frequency may vary). Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more information. See our Privacy Policy.

District Policy and Information regarding Leaves and Absences:

Medical Certificates to Doctor:

Employee’s personal medical reason, here is the Medical Form for your doctor to complete
- Employee’s serious health condition
- Certificado médico
Employee’s family member’s medical reason, here is the Medical Form for their doctor to complete:
- Family Member's serious health condition
- Certificado médico de family

Acknowledgement:required

I have read and understand the districts policies regarding leaves and absences.

Acknowledgement:required

Should my leave time need to be extended, I will provide updated medical documentation from the original healthcare provider.

Acknowledgement:required

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.

Acknowledgement:required

I understand that I may not be permitted to return to work until I provide medical documentation releasing me to return with restriction status.

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In This Section

Order of Leave

Contact Information

Inquiry:

Contact Information:

District Policy and Information regarding Leaves and Absences:

Medical Certificates to Doctor:

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