Berwyn South School District 100

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Hello D100 Staff
The following is the procedure when requesting Family Medical Leave ( FMLA).
Please complete all of the steps below.
  1. Log on to: FMLA Questionnaire Form and complete the google form.
  2. Below are FMLA Documents for your physician to complete with medical information.  Download the one pertinent to your situation.
  3. Send the completed document with original physician signature to Jane Bagus, Assistant Supt. at LaVergne Education Center.
  4. After all paperwork has been submitted and reviewed you will receive a Letter of Approval or Denial of the requested medical leave via US. mail and email at
  5. If you have any questions during this process please contact Jane Bagus via email at or by phone at 303-4021.