Forms and Documents

Documents

Forms

Religious accommodation Request form
reasonable accommodation request form

Worker's Compensation Injury Procedures

ALL work-related injuries or illnesses REQUIRE the completion of the Employee Injury Report form. If the injury derives from exposure to a bloodborne pathogen, please complete the “Occupational Exposure to Bloodborne Pathogen incident form”. These forms must be faxed to Human Resources (248-451-6889) before the district can authorize treatment.
The administrator in charge must complete the Supervisor Report of Accident form within 3 working days and forward to Human Resources.
If medical attention is required, employees must go to Concentra Medical Center located at 1915 N Perry St, Pontiac, MI 48340. For injuries occurring after 9 pm, please visit the ER at McLaren Hospital located on Perry Street in downtown Pontiac.
- Concentra is open from Mon-Fri 7 am to 9 pm and on Saturday from 9 am to 1 pm. If you choose to seek medical treatment it should be done within seven days of the injury. Human Resources must be notified and will send the authorization form.
All work status forms must be return to the Human Resources Department. You can either drop the forms off at the front desk or fax them to Human Resources at 248-451-6889.
If an employee is placed on restricted duty by the Concentra physician and is unable to perform his/her own job, Human Resources will attempt to place them in a restricted duty position until they are able to return to their regular duty work. Please contact Michael Emerson, 248-451-6809 or michael.emerson@pontiacschools.org if you are unable to work in your regular position due to a work related injury.
If a teacher is unable to perform his/her duties to a work place injury, please enter the absence as Worker’s Comp in AESOP. If you are unable to access that code, please enter the absence as Personal Illness and contact Michael Emerson at 248-451-6809 or michael.emerson@pontiacschools.org to correctly code the absence.
If you have further questions, please contact Michael Emerson in Employee Benefits at 248-451-6809 or michael.emerson@pontiacschools.org

All medical and or maternity leaves should be requested, in writing, stating the date the leave will begin and the expected date of return to work. Employees are required to provide 30 days notice for forseeable leaves of birth, adoption, foster care placement, or planned medical treatment.

Any Family Medical Leave Act (FMLA) eligible employee (employee must have worked for the district for 12 months and worked for 1,250 hours in the past 12 months) is entitled to apply for up to 12 weeks for unpaid FMLA leave. Please refer to your union contract for pay provisions while on leave.

Employees MUST complete the Request for Medical Leave Form first and return to the Human Resources/Benefits Department 30 days prior to your leave request (when possible). The Certification of Healthcare Provider should be completed by your physician and returned to the Benefits Department. More information is also available below in the FMLA Employee Guide. A determination will be made whether the leave is FMLA or non-FMLA. Please refer to your union contract for non-FMLA leave guidelines and eligibility.

Contact Michael Emerson, Benefits Coordinator memerson@pontiac.k12.mi.us for more information.

MEdical leave of absence request

Department of labor fmla fact sheet

FMLA guidelines

Physician certification - employee

physician certification - family member

certification for Qualifying exigency Military family leave

Certification for serious injury or illness of current service member

certification for serious injury or illness of veteran for military caregiver