Common use of EMPLOYEE'S STATEMENT Clause in Contracts

EMPLOYEE'S STATEMENT. I hereby authorize Xxxxxx Public Schools to contact my health care provider(s) to verify the reason for my requested leave or for any other information concerning my requested family or medical leave. I understand that this authorization will be used only if a medical certification is not received or it is incomplete. I understand that a failure to return to work at the end my leave period may be treated as a resignation and will serve as a basis for discharge unless an extension has been agreed upon and approved in writing by . Date Employee's Signature Approved by: Superintendent This page intentionally left blank. SAMPLE ADMINISTRATIVE FORMS 75

EMPLOYEE'S STATEMENT. I hereby authorize Xxxxxx Public Schools to contact my health care provider(s) to verify the reason for my requested leave or for any other information concerning my requested family or medical leave. I understand that this authorization will be used only if a medical certification is not received or it is incomplete. I understand that a failure to return to work at the end my leave period may be treated as a resignation and will serve as a basis for discharge unless an extension has been agreed upon and approved in writing by . _ Date Employee's Signature Approved by: Superintendent This page intentionally left blank. SAMPLE ADMINISTRATIVE FORMS 75FORMS

EMPLOYEE'S STATEMENT. I hereby authorize Xxxxxx Public Schools to contact my health care provider(s) to verify the reason for my requested leave or for any other information concerning my requested family or medical leave. I understand that this authorization will be used only if a medical certification is not received or it is incomplete. I understand that a failure to return to work at the end my leave period may be treated as a resignation and will serve as a basis for discharge unless an extension has been agreed upon and approved in writing by . Date Employee's Signature Approved by: Superintendent This page intentionally left blank. SAMPLE ADMINISTRATIVE FORMS 75FORMS