Leave of Absence Application from Humble Independent School District

If you will be absent more than 10 consecutive work days, you must file this Leave Application with the HR Dept prior to the start of the leave.

TYPE OF LEAVE:

Temporary Disability Leave (part-time OR worked for Humble ISD less than 1 yr)
Family/Medical Leave (full-time AND worked for Humble ISD longer than 1 yr)
Assault Leave (injured on school property/at event. Contact HR)
Intermittent FMLA (must be eligible for FMLA + have one recurrent medical issue)

Last Name
First Name
Location
Home Address
City
State	TX
Zip
Home Phone
Cell Phone
Personal Email
Month/Yr hired by Humble ISD
Work Schedule	Full-Time Part-Time

REASON FOR LEAVE:

Birth of your child, or placement of a child with you for adoption or foster care
A health condition that makes you unable to perform the essential functions of your job
A serious health condition affecting a family member for whom you must provide care

If caring for a family member:

Spouse
Child
Parent

Explain the medical situation:

Characters Available:

ANTICIPATED DATES OF LEAVE:

Last day of work:

Expected return date:

Note: Medical certification from a healthcare provider must accompany your leave request. Use the LINK below to send the medical certification by uploading it OR ask your doctor to fax it to HR.

Yawytrai Henry, Leave Coordinator
Phone: 281-641-8159 // Fax: 281-641-1057

Medical Certification Upload

I understand that I will be cease being paid unless I have enough paid leave time accrued to cover all or most of my anticipated leave. I further understand that, if eligible, FMLA will run concurrently with Temp Disability, Workers Comp, and Assault leave. I further understand that leave ends either at 90 OR 180 calendar days, OR if qualified, the last calendar day of the 6th month following the month leave without pay began. By submitting this form, I agree to the conditions of the Leave of Absence and that I will comply with the district's (campus and HR) procedures during the leave.

Please type your name and CLICK the BUTTON to sign digitally. Then click the Submit button.

Humble Independent School District - Leave of Absence Application