Your Rights. Family and Medical Leave Act of 1993

Transcription

1 Your Rights Under The Family and Medical Leave Act of 1993 FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for certain family and medical reasons. Employees are eligible if they have worked for a covered employer for at least one year, and for 1,250 hours over the previous 12 months, and if there are at least 50 employees within 75 miles. (There are also special provisions for teachers and other instructional employees of public and private elementary and secondary schools.) Reasons For Taking Leave: Unpaid leave must be granted for any of the following reasons: to care for the employee s child after birth, or placement for adoption or foster care; to care for the employee's spouse, son or daughter, or parent who has a serious health condition; or for a serious health condition that makes the employee unable to perform the employee's job. At the employee's or employer's option, certain kinds of paid leave may be substituted for unpaid leave. Advance Notice and Medical Certification: The employee may be required to provide advance leave notice and medical certification. Taking of leave may be denied if requirements are not met. The employee ordinarily must provide 30 days advance notice when the leave is foreseeable. An employer may require medical certification to support a request for leave because of a serious health condition, and may require second or third opinions (at the employer's expense) and a fitness for duty report to return to work. Job Benefits and Protection: For the duration of FMLA leave, the employer must maintain the employee's health coverage under any group health plan. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. The use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee s leave. Unlawful Acts By Employers: FMLA makes it unlawful for any employer to: interfere with restrain, or deny the exercise of any right provided under FMLA; discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA. Enforcement: The U.S. Department of Labor is authorized to investigate and resolve complaints of violations. An eligible employee may bring a civil action against an employer for violations. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights. For Additional Information: Contact the nearest office of the Wage and Hour Division, listed in most telephone directories under U.S. Government, Department of Labor.

2 FORM A Page 1 of 2 REQUEST FOR AND REPORT OF TIME OFF FROM WORK Employee Name: Department: Date: CHECK ONE: Report of absence from to. I request time off from work from through. Total Number of Days: I request time off from work as follows (describe intermittent or changed schedule leave requested):. REASON (Check all of these that apply): Vacation Family or Medical Leave Act ( FMLA ) Paid Sick Days Leave of Absence (complete next section) Jury Leave Extended Medical Leave (For FMLA-eligible) Military Leave Medical Leave (non-fmla) Bereavement Leave Other. Please specify: Yes No Time Off Request is due to a work-related injury or illness. The following information is needed to administer our Family or Medical Leave Act ( FMLA ) Policy: My request for time off from work is or is not [CHECK ONE] related to any of the following: The birth of a son or daughter, and the care of a newborn child. Placement of a child for adoption or foster care with me. Care of my spouse, child, or parent with a Serious Health Condition. * A Serious Health Condition that makes me unable to work at all or unable to perform any one of the essential functions of my job. NOTE: If any of the above four boxes are checked, please complete Form B. Additionally, please consult the Company Summary of Policies or the Human Resources Manager for eligibility requirements for an FMLA leave and a definition of the FMLA term Serious Health Condition. FULL-TIME EMPLOYEES, REQUESTING A MEDICAL LEAVE OF ABSENCE, WHO PARTICIPATE IN THE MEDICAL INSURANCE PLAN, MUST INITIAL IF THIS BOX IS MARKED: Employee Initials: If I am on a paid FMLA or non-fmla leave of absence, I understand that my portion of any applicable medical insurance coverage premium will be paid through payroll deduction during that portion of the paid FMLA or non- FMLA leave of absence. If the FMLA or non-fmla leave is unpaid, I agree to pay my portion of that premium on or before the 1st day of each month while I am on leave. I understand that if payment is not made timely, and after required notification, my medical coverage may be cancelled. I further agree that if Company opts to pay my portion of that insurance premium during an unpaid FMLA or non-fmla leave, I agree to reimburse it for the full cost upon my return from FMLA or non-fmla leave through a personal check or appropriate payroll deductions. If I fail to return from FMLA or non-fmla leave, I also agree that I must pay the full amount due and owing within 30 calendar days. If I fail to do so, this agreement is enforceable against me as an acknowledgement of a valid debt and that I shall be liable for any and all costs incurred, including attorneys fees, as a result of my failure to repay the full amount owed. In order to continue any applicable group health insurance after the expiration of any applicable non-fmla leave, I understand I must make a COBRA Continuation of Coverage Election.

3 FORM A Page 2 of 2 I certify that this information is correct, that I shall review and abide by Company s Leaves of Absence Policy, and that I intend to return to work after the expiration of any leave that may be granted to me based on this request for time off work. I understand that an employee s return from a FMLA leave will be governed by the FMLA. With regard to all other leaves, I understand that if I properly return from that leave, I may be assigned to the position I held prior to that leave if it is vacant and Company decides to fill it. Unless otherwise prohibited by law, if I fail to report for work upon the expiration of my leave of absence and have not secured an approved leave extension in advance, I will be terminated from my employment. DATE: EMPLOYEE SIGNATURE IF RECEIVED BY PHONE: DATE: PERSON RECEIVING MESSAGE CALLER (IF NOT EMPLOYEE): * * * * * * Company Response (check one or more that is appropriate): Request conditionally granted. Dates and times of Leave: Date: Request granted. Dates and times of Leave: Leave is with pay or without pay [CHECK ONE]. If pay covers only part of the leave of absence, it is with pay from to. Request denied, because (Signature of Company Representative) * PLEASE CONSULT COMPANY S SUMMARY OF POLICIES OR THE HUMAN RESOURCES MANAGER FOR FMLA ELIGIBILITY REQUIREMENTS, A DEFINITION OF THE TERM SERIOUS HEALTH CONDITION, AND ADDITIONAL INFORMATION CONCERNING FMLA AND NON-FMLA LEAVES OF ABSENCE.

4 FORM B Page 1 of 1 NOTICE AND APPLICATION FOR FAMILY OR MEDICAL ( FMLA ) LEAVE Employee Name: Date: CHECK ONE: I request time off from work from through. I request time off from work as follows (Describe any intermittent or reduced leave schedule that is medically necessary):. This schedule will remain in effect from through. My request for an FMLA Leave is based on the following: a. The birth of a son or daughter, and the care of a newborn child. b. Placement with me of a child for adoption or foster care. c. Care of my spouse, child, or parent with a Serious Health Condition (see definition below). d. A Serious Health Condition * that makes me unable to work at all or unable to perform any one of the essential functions of my job. FULL-TIME EMPLOYEES, REQUESTING A MEDICAL LEAVE OF ABSENCE, WHO PARTICIPATE IN THE MEDICAL INSURANCE PLAN, MUST INITIAL IF THIS BOX IS MARKED: Employee Initials: If I am on a paid FMLA or non-fmla leave of absence, I understand that my portion of any applicable medical insurance coverage premium will be paid through payroll deduction during that portion of the paid FMLA or non-fmla leave of absence. If the FMLA or non-fmla leave is unpaid, I agree to pay my portion of that premium on or before the 1st day of each month while I am on leave. I understand that if payment is not made timely, and after required notification, my medical coverage may be cancelled. I further agree that if Company opts to pay my portion of that insurance premium during an unpaid FMLA or non-fmla leave, I agree to reimburse it for the full cost upon my return from FMLA or non-fmla leave through a personal check or appropriate payroll deductions. If I fail to return from FMLA or non-fmla leave, I also agree that I must pay the full amount due and owing within 30 calendar days. If I fail to do so, this agreement is enforceable against me as an acknowledgement of a valid debt and that I shall be liable for any and all costs incurred, including attorneys fees, as a result of my failure to repay the full amount owed. In order to continue any applicable group health insurance after the expiration of any applicable non-fmla leave, I understand I must make a COBRA Continuation of Coverage Election. This Notice and Application should be accompanied by a Certification of Physician or Practitioner (Form D) if it is based on a Serious Health Condition affecting you or your spouse, child, or parent. Generally, if not accompanying this Notice and Application, the Certification should be provided within two business days thereafter. If it is based on the birth or placement of a child or the care of a newborn child, it should be accompanied by such other verifying information as Company has requested. Please note that the conditions regarding the application and granting of a FMLA Leave are set forth in Company s FMLA Leave policy. Also review the Notice of the Granting or Denying of a FMLA Leave Form C. I certify that this information is correct, that I shall abide by Company s Leaves of Absence Policy, and that I intend to return to work after the expiration of any leave that may be granted to me based on this request for time off work. I understand that an employee s return from a FMLA leave will be governed by the FMLA. With regard to all other leaves, I understand that if I properly return from that leave, I may be assigned to the position I held prior to that leave if it is vacant and Company decides to fill it. Unless otherwise prohibited by law, if I fail to report for work upon the expiration of my leave of absence and have not secured an approved leave extension in advance, I will be terminated from my employment. DATE: EMPLOYEE SIGNATURE * Please consult Company s Leaves of Absence Policy or the Human Resources Manager for eligibility requirements, a definition of the FMLA term Serious Health Condition, and additional information concerning FMLA and non-fmla leaves of absence.

5 FORM C Page 1 of 2 Employee Name: NOTICE TO EMPLOYEE GRANTING OR DENYING OF FAMILY OR MEDICAL ( FMLA ) LEAVE Notice/Request: Date: Request for a FMLA Leave is based on the following (Check one): a. The birth of a son or daughter, and the care of a newborn child. b. Placement with you of a child for adoption or foster care. c. Care of your spouse, child, or parent with a Serious Health Condition. d. A Serious Health Condition that makes you unable to work at all or unable to perform any one of the essential functions of your job. Company s Action: FMLA Leave of Absence denied, because FMLA Leave of Absence granted, as follows (Check one and complete): FMLA Leave is granted from through. FMLA Leave is granted as follows regarding your time off from work request on an intermittent or reduced leave schedule basis (Describe any intermittent or reduced leave schedule that is medically necessary): This schedule will remain in effect from through.. This FMLA Leave of Absence may be renewed for periods not to exceed 35 calendar days by making notice and application prior to the expiration of the leave then in effect, as long as the employee is entitled to additional FMLA Leave. Any requested renewal of this FMLA Leave should be accompanied by a medical certification supporting renewal. This certification is required at the time of the request for renewal or within 15 calendar days after this notice that recertification is required, whichever is later. This FMLA Leave is with pay or without pay [CHECK ONE]. If pay covers only a part of the FMLA Leave, it is with pay from to. Additional Information Required (Check any that apply): This leave of absence will be charged against both your entitlement to 12 weeks of FMLA Leave and under any other applicable fringe benefit plan (e.g., vacation, paid sick days, short-term disability, long-term disability). A medical certification, if not already provided, within 15 calendar days of the day on which this Notice is received unless it is not practicable under the particular circumstances to do so despite the employee s diligent, good faith efforts. Forms are enclosed. Failure to provide this certification (or other documentation/information) may result in delay of the employee s leave request. If the employee does not produce the requested certification (or other documentation/information), the leave will not be considered FMLA leave. Information verifying the need for a FMLA Leave, including: Generally speaking and depending upon the basis of the employee s FMLA need, Company may request recertifications no more often than every 35 days. There are certain exceptions to this 35 day period. You will be notified of any applicable recertification requirement.

6 FORM C Page 2 of 2 While you are on this FMLA Leave, you also will be required to substitute any unused and applicable paid vacation and/or sick days for any unpaid FMLA leave. Additionally, your FMLA leave of absence shall run concurrent with any applicable short-term and/or long-term disability pay policy absence. It also shall run concurrent with any applicable workers compensation absence when the workers compensation injury or illness meets the criteria for a Serious Health Condition. During this FMLA Leave, and if applicable, the employee s medical insurance will remain in effect. Payment of the employee s share, if applicable, of any medical insurance premium for coverage during this FMLA Leave will be paid by the employee through payroll deduction during any portion of the leave that is paid. During any period of time in which an employee is on an unpaid FMLA Leave, payment of the employee s share of any medical insurance premium (if applicable) must be paid. During any period of time in which an employee is on an unpaid FMLA Leave, payment of the employee s share of any medical insurance premium must be paid by the employee to Company on or before the 1st day of the month for which the premium contribution is due. You have a minimum 30 calendar day grace period in which to make any applicable premium payments. If payment is not made timely, and after required notification, your medical insurance coverage may be cancelled. At Company s option, it may pay your share of the premiums during FMLA leave, and recover these payments from you through a personal check or appropriate payroll deductions upon your return to work. An employee who has been on a FMLA Leave of Absence because of a Serious Health Condition that affects the employee shall provide to Company a fitness-for-duty certification that he/she is able to resume work at the time he/she returns. An employee who does not provide this certification will not be permitted to return to work until such a certification is provided. If an employee discovers that his or her circumstances have changed and the amount of leave originally anticipated is no longer necessary, the employee must provide Company reasonable notice (i.e., within two business days) of his or her intent to return to work. An employee who returns from a FMLA Leave shall return to the position held at the beginning of the leave or to an equivalent position with equivalent employment benefits, pay, and other terms and conditions of employment, provided, however, that an employee is not entitled to return to a position other than that to which he/she would have been entitled had the employee not taken the leave. Special rules apply to certain key employees. An employee affected by these rules will be notified by Company. Please consult Company s Leaves of Absence Policy for additional information regarding your FMLA leave. Company Representative Date

7 FORM D Page 1 of 3 CERTIFICATION OF HEALTH CARE PROVIDER (Family and Medical Leave Act of 1993) 1. Employee s Name: 2. Patient s Name (if different from employee): 3. The attached sheet describes what is meant by a Serious Health Condition under the Family and Medical Leave Act. Does the patient s condition 1 qualify under any of the categories described? If so, please check the applicable category. (1) (2) (3) (4) (5) (6), or None of the above 4. Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories: 5. a. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient s present incapacity 2 if different): b. Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in Item 6 below)? If yes, give the probable duration: c. If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated 2 and the likely duration and frequency of episodes of incapacity 2 : 6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments: If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any: b. If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the treatments: 1 Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave. 2 Incapacity, for purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily activities due to the Serious Health Condition, treatment therefor, or recovery therefrom.

8 FORM D Page 2 of 3 c. If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g., prescription drugs, physical therapy requiring special equipment): 7. a. If medical leave is required for the employee s absence from work because of the employee s own condition (including absences due to pregnancy or a chronic condition), is the employee unable to perform work of any kind? Yes No b. If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee s job (the employee or the employer should supply you with information about the essential job functions)? If yes, please list the essential functions the employee is unable to perform: c. If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment? Yes No Explain: 8. a. If leave is required to care for a family member of the employee with a Serious Health Condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation? b. If no, would the employee s presence to provide psychological comfort be beneficial to the patient or assist in the patient s recovery? c. If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need: (Signature of Health Care Provider) (Type of Practice) (Print Name of Health Care Provider) (Telephone Number) (Address) (Date) To be completed by the employee needing family leave to care for a family member: State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule: This information is correct. (Employee signature) (Date) * * * * * * * *

9 FORM D Page 3 of 3 A Serious Health Condition means an illness, injury, impairment, or physical or mental condition that involves one of the following: 1. Hospital Care Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity 2 or subsequent treatment in connection with or consequent to such inpatient care. 2. Absence Plus Treatment (a) A period of incapacity 2 of more than three consecutive calendar days (including any subsequent treatment or period of incapacity 2 relating to the same condition), that also involves: (1) Treatment 3 two or more times by a health care provider, by a nurse or physician s assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or (2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment 4 under the supervision of the health care provider. 3. Pregnancy Any period of incapacity due to pregnancy, or for prenatal care. 4. Chronic Conditions Requiring Treatments A chronic condition which: (1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician s assistant under direct supervision of a health care provider; (2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and (3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.). 5. Permanent/Long-term Conditions Requiring Supervision A period of incapacity 2 which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimer s, a severe stroke, or the terminal stages of a disease. 6. Multiple Treatments (Non-Chronic Conditions) Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity 2 of more than three consecutive days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis). 3 Treatment includes examinations to determine if a Serious Health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or dental examinations. 4 A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.

10 FORM E Page 1 of 1 FITNESS FOR DUTY CERTIFICATION (Family and Medical Leave Act of 1993 ( FMLA )) To: Physician or Practitioner Please complete all of the following and sign. Employee s Name: Notice to Physician or Practitioner: The employee named above has been off of work from through on an FMLA Leave, or The employee named above has been absent from work on an FMLA Leave either intermittently or on a reduced schedule as follows (describe schedule and duration of schedule): The Serious Health Condition that caused this FMLA Leave was diagnosed as follows (from medical certification): I hereby certify that this employee is, or is not (Check One), able to return to work, or to his or her regular schedule, based on the Serious Health Condition diagnosed above. Physician or Practitioner Information: Name: (Print) Address: Telephone: The above provided information is correct and based on reasonable medical certainty: Signature of Physician or Practitioner Date

11 FORM F Page 1 of 2 CERTIFICATION OF HEALTH CARE PROVIDER (Medical Leave of Absence) * PLEASE PRINT OR WRITE LEGIBLY * 1. Employee s Name: 2. Patient s Name (if different from employee): 3. Identify the patient s medical condition: 4. Describe the medical facts which support your certification: 5. State the approximate date the condition commenced: 6. State the probable duration of the condition (and also the probable duration of the employee s present incapacity if different): 7. Does the employee need to be absent from work due to the above-referenced condition? Yes No 8. Describe the medical facts which support your answer to Question No. 7: 9. If the employee needs to be off work, please list the beginning date of the need for medical leave and the date the employee can return to work: 10. Describe the medical facts which support your answer to Question No. 9: 11. a. Can the employee perform work of any kind? Yes No 1. If no, describe the medical facts which support your answer:

12 FORM F Page 2 of 2 2. If yes, can the employee perform any one or more of the essential functions of the employee s job (the employee and/or the employer should supply you with information about the essential job functions)? Yes No If yes, please list the essential functions the employee can perform: If no, describe the medical facts which support your answer: Could the employee perform the essential functions with a reasonable accommodation? Yes No If yes, describe the suggested reasonable accommodation(s): If no, describe the medical facts which support your answer: b. If the employee can work, will it be necessary for the employee to be absent from work for treatment? Yes No Describe the medical facts which support your answer: 12. Considering the employee s medical condition and treatment, state the approximate date you expect him/her to return to work: 13. If unable to give an exact return to work date, please explain: The above provided information is correct and based on reasonable medical certainty. (Signature of Health Care Provider) (Type of Practice) (Print Name of Health Care Provider) (Telephone Number) (Address) (Date)

13 FORM G Page 1 of 1 FITNESS FOR DUTY CERTIFICATION (Medical Leave of Absence) * PLEASE PRINT OR WRITE LEGIBLY * To: Physician or Practitioner Please complete all of the following and sign. Employee s Name: Notice to Physician or Practitioner: The employee named above has been off of work from through on a Medical Leave of Absence, or The employee named above has been absent from work either intermittently or on a reduced schedule as follows (describe schedule and duration of schedule): The medical condition that caused this leave was diagnosed as follows (from medical certification): I hereby certify that this employee is, or is not (Check One), able to return to work, or to his or her regular schedule, based on the medical condition diagnosed above. The above provided information is correct and based on reasonable medical certainty: (Signature of Health Care Provider) (Type of Practice) (Print Name of Health Care Provider) (Telephone Number) (Address) (Date)