FEDERAL AND WISCONSIN FAMILY AND MEDICAL LEAVE LAWS

FEDERAL AND WISCONSIN FAMILY AND MEDICAL LEAVE LAWS EMPLOYEE'S GUIDE AND NOTICE OF RIGHTS REVISED AND RESTATED EFFECTIVE FOR JANUARY 16, 2009 IN RESPONSE TO THE FEDERAL WAGE AND HOUR DIVISION S FINAL RULE ON FMLA (changes are identified in bold print) Office of Employee Services

TABLE OF CONTENTS Q. What is Family and Medical Leave (FML)?...4 Q. Am I eligible?...5 Q. What do spouse, parent and son or daughter mean for purposes of qualifying to take FMLA leave?...5 Q. What does Next of Kin mean for purposes of qualifying for care of an injured/recovering military service member?...5 Q. What does Son or Daughter of a covered service member or Son or Daughter on active duty or call to active duty status mean for purposes of qualifying for FMLA in relation to the National Defense Authorization Act (NDAA)?...6 Q. What is a "serious health condition?"...6 Q. How is "continuing treatment by a health care provider" defined?...6 Q. What does it mean that an employee is "needed to care for" a family member?...7 Q. When may intermittent or reduced leave be utilized?...7 Q. What notice do you have to give the District when the need for FMLA leave is foreseeable?...7 Q. What are the consequences of failing to provide required notification to the District?...8 Q. When must you provide a medical certificate to support a FMLA leave request?...8 Q. What can the District request of you if it questions the adequacy of a medical certification?...8 Q. Will a medical certificate be required to return to work?...9 Q. What special FMLA rules apply to employees of schools?...9 Q. When is FMLA exhausted?...10 Q. Does FMLA leave have to be taken all at once or can it be taken in parts?...10 Q. May the District transfer you to an "alternate position" to accommodate your request for intermittent or a reduced leave schedule?...10 Q. Is FMLA paid or unpaid?...11 Q. What benefits are you entitled to while using FMLA leave?...11 Q. What are the consequences if you fail to make timely health plan premium payments?...11 Q. May the District recover its contribution to health insurance premiums for maintaining your coverage during FMLA leave?...11 Q. What are your rights to return to work from FMLA leave?...11 Q. Are there any limitations on the District's obligation to reinstate you?...12 Q. If you exercise your FMLA leave rights, how are you protected?...12 Q. Under what circumstances can the District refuse to provide FMLA or reinstatement to eligible employees?...12 Q. How does the Family and Medical Leave Laws affect state laws, District master contracts and personnel policies?...13 2

Family and Medical Leave 3 TABLE OF CONTENTS (CONT ) FMLA RELATED FORMS...14 Employee Leave Request Form...15 Physician Certification for Employee s Serious Illness...16 Physician Certification for Family Member s Serious Illness...20 Fitness to Return to Work and Functional Analysis Form...24 MILITARY FMLA FORMS...26 Certification of Qualifying Exigency for Military Family Leave...27 Certification of Serious Illness or Injury of a Covered Service Member for Military Family Leave...30 3

Family and Medical Leave 4 EMPLOYEE'S GUIDE TO THE FAMILY AND MEDICAL LEAVE POLICY OF THE MIDDLETON-CROSS PLAINS AREA SCHOOL DISTRICT The purpose of this document is to identify for employees the basic features of the Federal and Wisconsin family and medical leave laws and the Policy of the District on the taking of Family and Medical Leave. The information contained in this Guide is not intended to be a complete representation of all facets of these important laws or a full explanation of the District's Policy, but only a summary to help you understand the laws and your rights and obligations under the Policy of the District. Contact the Office of Employee Services if you wish to obtain additional information regarding the District Policy. The District administers its Family and Medical Leave Law ("FMLA") obligations on a calendar year basis. To that extent the reasons for leave would entitle an employee leave under the federal and Wisconsin law, the leaves will run concurrently, along with any leave to which the employee is entitled under the applicable Policy of the District. Q. What is Family and Medical Leave (FML)? The Family and Medical Leave Act of 1993 (FMLA), a federal law, gives an eligible employee up to twelve (12) weeks of leave for the birth or placement of a child for adoption or foster care; to care for the employee's spouse, child or parent with a serious health condition; and for a serious health condition that makes the employee unable to perform the essential functions of the employee's job. A week of leave is equivalent to the number of hours worked per week by the employee. An employee on FMLA leave is also entitled to have health insurance benefits maintained while on leave as if the employee had continued to work instead of taking leave. Amendments to FMLA (Section 585 of the National Defense Authorization Act (NDAA) for FY 2008) - Among other things, amends FMLA to permit a spouse, son, daughter, parent, or next of kin to take up to 26 workweeks of leave to care for a member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness." Further, the NDAA expanded the definition of the FMLA to provide for additional job-protected leave rights to eligible employees because of qualifying exigencies (need/demand) arising out of the fact that a covered military member is on active duty or has been notified of an impending call or order to active duty in support of a contingency operation. The reasons for which an employee can take leave because of a qualifying exigency are (1) Short-notice deployment; (2) Military events and related activities; (3) Childcare and school activities; (4) Financial and legal arrangements; (5) Counseling; (6) Rest and recuperation; (7) Post-deployment activities; and (8) Additional activities. The Wisconsin Family and Medical Leave Law also allows eligible employees to take a leave from employment. Under Wisconsin law, an employee may take up to six (6) weeks of leave for the birth or placement of a child for adoption; 2 weeks to care for the employee's spouse, child or parent with a serious health condition; and 2 weeks for a serious health condition which renders the employee unable to perform the essential functions of the employee's job. The District has combined its obligations under these two laws to form the current FMLA Policy of the District. The below information reflects the rights of employees under the laws as administered by the District. 4

Family and Medical Leave 5 Q. Am I eligible? You are eligible for Federal FML if you have been employed by the District for at least twelve months and have worked for at least 1,250 hours during the twelve month period immediately preceding the commencement of the leave. To qualify for Wisconsin FML, you must have worked for the District for 52 consecutive weeks and at least 1,000 hours in the preceding 52 weeks. Q. What do spouse, parent and son or daughter mean for purposes of qualifying to take FMLA leave? Spouse means husband or wife as recognized under Wisconsin law for purposes of marriage. Unmarried domestic partners do not qualify for family leave to care for their partner. Parent means biological parent or an individual responsible for the day-to-day care of the child. The term does not include "parents-in-law." However, under Wisconsin law you are entitled to take your two weeks of family leave to care for a parent-in-law with a serious health condition. Child means a natural, adopted, foster or treatment foster child, a stepchild or a legal ward to whom any of the following applies: 1. The individual is less than 18 years of age. 2. The individual is 18 years of age or older and cannot care for himself or herself because of a serious health condition. "Incapable of self-care" means that the child requires active assistance or supervision to provide daily selfcare in several of the "activities of daily living." Activities of daily living include adaptive activities such as activities of caring appropriately for one's grooming or hygiene, bathing, dressing, eating, cooking, shopping, taking pubic transportation, paying bills, maintaining a residence, using telephones or directories, using a post office, etc. "Physical or mental disability" means a physical or mental impairment that substantially limits one or more major life activities of the individual. Q. What does Next of Kin mean for purposes of qualifying for care of an injured/recovering military service member? The National Defense Authorization Act (NDAA) defines Next of Kin as the nearest blood relative other than the covered service member s spouse, parent, son, or daughter, in the following order of priority: Blood relatives who have been granted legal custody of the covered service member by court decree or statutory provisions, brothers and sisters, grandparents, uncles, aunts, first cousins, unless the covered service member has specifically designated in writing another blood relative as his/her nearest blood relative for purposes of military caregiver leave under the FMLA. When the service member has designated someone as next of kin the designated individual shall be deemed to be the covered service member s only next of kin. 5

Family and Medical Leave 6 Q. What does Son or Daughter of a covered service member or Son or Daughter on active duty or call to active duty status mean for purposes of qualifying for FMLA in relation to the National Defense Authorization Act (NDAA)? Includes biological, adopted, or foster child, stepchild, legal ward, or a child for whom the covered service member and/or employee stood in loco parentis and who is of any age. Q. What is a "serious health condition?" A serious health condition means an illness, injury, impairment, or physical or mental condition that involves: 1. Any period of incapacity or treatment in connection with or subsequent to inpatient care in a hospital, hospice or residential medical facility; 2. Any period of incapacity requiring absence from work, school or other regular daily activities of more than three (3) consecutive calendar days that also involves continuing treatment or supervision by a health care provider; 3. Continuing treatment by (or under the supervision of) a health care provider for a chronic or longterm health condition that is incurable or so serious that if not treated, would likely result in a period of incapacity of more than three (3) calendar days; or 4. Pregnancy or prenatal care. Q. How is "continuing treatment by a health care provider" defined? Continuing treatment by a health care provider means one or more of the following: 1. The employee or family member in question is treated two or more times for the injury or illness by a health care provider. This requires first hand, hands-on treatment or care by a health care provider including a physician's assistant under the direct supervision of the health care provider. 2. The employee or family member is treated for an injury or illness two or more times by a provider of health care services under orders of, or on referral by, a health care provider; or is treated for the injury or illness by a health care provider on at least one occasion which results in a medical regime of continuing treatment under the supervision of a health care provider to resolve the health condition. 3. The employee or family member is under the continuing supervision of, but not necessarily being actively treated by, a health care provider due to a long-term or chronic condition or disability which cannot be cured. Examples include persons with Alzheimer's, persons who have suffered a severe stroke or persons in the terminal stages of a disease who may not be receiving active medical treatment. 4. Prenatal care is included as a serious health condition. Voluntary or cosmetic treatment (such as medical check-ups, most treatments for orthodontia or acne) which are not medically necessary are not "serious health conditions" unless inpatient hospital care is required. Treatments for allergies, stress or for substance abuse are serious health conditions if all the conditions of the regulations are met. Prenatal care is included as a serious health condition. Routine preventative physical examinations are excluded. 6

Family and Medical Leave 7 Q. What does it mean that the "employee is unable to perform the functions of his or her position?" An employee is unable to perform the functions of the position where the health care provider finds that the employee is unable to work at all or is unable to perform the critical functions of the employee's position. An employee who must be absent from work to receive medical treatment for a serious health condition is considered to be unable to perform the essential functions of the position during the absence for treatment. For a copy of the essential functions of your position, contact your immediate supervisor or the Office of Employee Services. Q. What does it mean that an employee is "needed to care for" a family member? "Needed to care for" includes both physical and psychological care. The term also includes situations where the employee may be needed to fill in for others who are caring for the family member, or to make arrangements for changes in care, such as transfer to a nursing home. Q. When may intermittent or reduced leave be utilized? Intermittent leave or leave on a reduced schedule may be utilized when there is a qualifying medical need for leave that can be accommodated through periodic absences from work. Employees needing intermittent or a reduced leave schedule must attempt to schedule their leave so as not to disrupt the District's operations. In making this determination, the District will take into account the operational needs of the District and the interests of the children in meeting their educational needs. Intermittent or reduced schedule leave may be used by an employee not only in the situation where the family member's condition is intermittent, but also where the employee is needed only intermittently to care for such individual such as where other care is normally available, or care responsibilities are shared by another member of the family or a third party. Q. What notice do you have to give the District when the need for FMLA leave is foreseeable? You must provide the District with at least 15 days advance notice if the reason for leave is foreseeable. If leave is not foreseeable, notice must be given as soon as practicable, but in no event later than two (2) days after the absence from work began. This notice must be in writing and delivered to the Office of Employee Services. If the need for leave is unforeseen, i.e., in the event of an emergency, an employee must provide at least verbal notice sufficient to make the District aware that the employee needs FMLA-qualifying leave, including the anticipated duration of leave. This notice must be provided to the District within two (2) business days of the commencement of the leave. When planning medical treatment, whether for the employee or someone who the employee will care for, the employee should consult with the District before scheduling treatment and make a reasonable effort to schedule the leave so as to not unduly disrupt the District's operations or needs of the children, subject to the approval of the health care provider. The District may request the employee to reschedule treatment, subject to the approval of the health care provider. In the case of a request for medically necessary intermittent or reduced schedule leave, the employee must advise the District, in writing, of the reasons why the intermittent or reduced leave schedule is necessary 7

Family and Medical Leave 8 and the schedule for treatment, if applicable. The District and the employee shall attempt to work out a schedule that meets the employee's needs without unduly disrupting the District's operations or needs of the children, subject to the approval of the health care provider. The District may transfer an employee to an alternate position during the period of intermittent or reduced schedule leave which better accommodates the schedule of leave. Q. What are the consequences of failing to provide required notification to the District? If you fail to give advance notice under the District's Policy for foreseeable leave, with no reasonable excuse for the delay, the District may deny the taking of FMLA leave for up to fifteen days after the date the employee provides notice to the District of the need for leave to locate a satisfactory replacement. Q. When must you provide a medical certificate to support a FMLA leave request? You must provide the District with a Health Care Provider Certification in the event of a serious health condition, whether for your condition or that of another covered person. You will be provided with a Certification form by your supervisor or the Office of Employee Services. When requesting medical leave which is foreseeable, you have fifteen (15) calendar days after receipt in which to provide the requested Certification. The Health Care Provider Certification must be prepared by, and signed by, the health care provider. In the case of a medical emergency, an employee must provide a completed Certification form within a reasonable time, as determined by the relevant facts and circumstances, but in no event later than fifteen (15) days after the Health Care Provider Certification form is provided to you. Failure to provide the Certification may result in denial of the FMLA leave request or delay of the leave request until an adequate certification is received. Q. What can the District request of you if it questions the adequacy of a medical certification? If you submit a completed Health Care Provider Certification signed by a health care provider, the District may not request additional information from the health care provider. Rather, the District may require you to obtain a second opinion from a health care provider selected by the District, at the District's expense. If the second opinion is in disagreement with the original medical certification, then a third opinion may be requested by the District. In this case, a third health care provider will be selected to render the third opinion. This third opinion will be final and binding upon the parties. The District is responsible for the expense of the third opinion. The District may request recertification as to the continuance of the serious health condition at any reasonable interval of time but not more often than every thirty (30) days unless: 1. the employee requests an extension of leave; 2. the circumstances described by the original certification have changed significantly; 3. the District receives information that casts doubt on the continuing validity of the certification; or 4. the employee indicates that he/she is unable to return to work because of the continuation, reoccurrence, or onset of the serious health condition. 8

Family and Medical Leave 9 Q. Will a medical certificate be required to return to work? If you are on FMLA leave for your own serious health condition, you will be required to present a certification from your health care provider prior to being allowed to return to work indicating that you are able to return to your position at work and perform the essential functions of your job. If you are not able to perform all of your duties upon the expiration of leave, please contact the Office of Employee Services to further discuss your employment with the District. The District may require you to periodically report your status and intention to return to work. The District may deny restoration to employment until you submit the required fitness for duty certification. Q. What special FMLA rules apply to employees of schools? If you are employed principally in an instructional capacity and request a leave that is foreseeable based upon planned medical treatment and would be on leave for greater than 20% of the total number of working days in the period in which the leave would extend, the District may require you to elect either: 1. to take leave for periods of a particular duration not to exceed the duration of a planned medical treatment; or 2. to transfer temporarily to an available alternative position offered by the District for which you are qualified and that has equal pay and benefits and better accommodates reoccurring periods of leave than your regular position. If you are principally employed in an instructional capacity and are requesting FMLA leave that begins more than five weeks prior to the end of the semester, the District may require you to continue taking leave until the end of the semester if: 1. the leave is of at least three weeks duration and 2. the return to employment would occur during the three week period before the end of the semester. If you are employed principally in an instructional capacity and are requesting FMLA leave because of the birth, adoption or foster care placement of a child or to care for a spouse, child or parent, other than an inlaw, with a serious health condition during the period that commences five weeks prior to the end of the semester, the District may require you to continue taking leave until the end of the semester if: 1. the leave is greater than two weeks duration; and 2. the return to employment would occur during the two week period before the end of the semester. If you are employed principally in an instructional capacity and are requesting FMLA leave because of the birth, adoption or foster care placement of a child or to care for a spouse, son, daughter or parent, other than an in-law, with a serious health condition during the period that commences three weeks prior to the end of the semester and the duration of leave is greater than five working days, the District may require you to continue to take leave until the end of the semester. 9

Family and Medical Leave 10 Q. When is FMLA exhausted? You are entitled to take up to twelve (12) weeks of FMLA leave during the calendar year and up to twenty-six (26) weeks for care of an injured/recovering service member. Your Wisconsin leave entitlement will run concurrently with your federal leave to the extent your reason for leave satisfies the requirement for leave under each such law. For example, if you are absent from work for 12 weeks as a result of your serious health condition, you will have exhausted your federal leave entitlement as well as your two (2) weeks of Wisconsin leave for your serious health condition. The FMLA leave, federal and Wisconsin, that you are entitled to will also run concurrently with any leave you take or are entitled to take under the policies of the District which are permitted on your serious health condition. For example, workers compensation leave will run concurrently with your FMLA entitlement. Q. Does FMLA leave have to be taken all at once or can it be taken in parts? FMLA leave may be taken intermittently or on a reduced leave schedule under certain circumstances. For the birth or placement of a child, leave on an intermittent or reduced schedule basis is available for leave commencing during the first sixteen (16) weeks before or after the birth. The last segment of intermittent or reduced schedule leave must be commenced before the expiration of the sixteen (16) week period. Thereafter intermittent or reduced scheduled leave is only available if approved in advance by the District. When leave is taken for a sick family member or for the employee's own serious health condition, leave may be taken intermittently or on a reduced leave schedule when medically necessary. There is no limit, other than the maximum period of leave available, on the size of an increment of leave when an employee takes intermittent leave or leave on a reduced leave schedule under this Policy except that the District may limit leave increments to the shortest period of time that the District's payroll system uses to account for absences or use of leave. Only the amount of leave actually taken will be counted toward the employee's FMLA entitlement. The Superintendent's approval will be necessary for intermittent leave or leave in a reduced schedule which is not recommended on the medical certificate but requested by the employee. Q. May the District transfer you to an "alternate position" to accommodate your request for intermittent or a reduced leave schedule? For intermittent or reduced schedule leave that is foreseeable based on planned medical treatment, the District may transfer you temporarily to an available alternative position for which you are qualified and which better accommodates reoccurring periods of leave. Although the alternative position must have equivalent pay and benefits, the position does not have to have equivalent duties. The District may also transfer you to a part-time position with the same hourly rate of pay and benefits. However, you will accrue employment benefits during the period of leave on the basis of the hours 10

Family and Medical Leave 11 of employment. The District will not eliminate benefits which otherwise would not be provided to part-time employees. Q. Is FMLA paid or unpaid? FMLA leave is unpaid. An employee may utilize accrued reimbursable leave while on FMLA leave. Paid vacation or paid personal leave may also be utilized at the employee's request. Q. What benefits are you entitled to while using FMLA leave? The District will maintain your group health plan coverage on the same conditions as coverage would have been provided if you had been continuously employed during the leave period. The District's existing rules for payment of health benefit premiums while on leave without pay will be followed. Contact the benefits department in the Office of Employee Services to discuss your particular payment requirements. Q. What are the consequences if you fail to make timely health plan premium payments? You have a thirty (30) day grace period after the agreed upon date for payment of premiums without affecting your health insurance coverage. If you do not make the payment within the thirty (30) day grace period, the District may terminate your health insurance coverage. If you have questions or problems on the coverage payments, please contact the Office of Employee Services. Q. May the District recover its contribution to health insurance premiums for maintaining your coverage during FMLA leave? If you fail to return to work for reasons unrelated to FMLA leave or not for circumstances beyond your control, health insurance premiums paid by the District during the period of FMLA leave, i.e., the District's portion as well as any employee portion paid by the District, are a debt owed by you to the District. An employee who returns to work for at least thirty (30) calendar days is considered to have "returned" to work. The District may recover health insurance premiums paid on the behalf of an employee through deduction of any sums due to you from employment. Any deficiency will be due from the employee. The District, if necessary, may initiate legal action against you to recover unpaid health insurance premiums. Q. What are your rights to return to work from FMLA leave? Upon the expiration of your FMLA leave, you will be returned to the same or an equivalent employment position having equivalent benefits, pay and other terms and conditions of employment. The position will involve the same or substantially similar duties and responsibilities, which entails substantially equivalent skill, effort, responsibility and authority. If you are no longer qualified for the position at the end of the leave, you may be considered for other available employment at the District. 11

Family and Medical Leave 12 Q. Are there any limitations on the District's obligation to reinstate you? You are entitled to no greater right to reinstatement or to any other benefit or condition of employment upon returning from FMLA leave than you would have had if continuously employed during the FMLA leave. The District has the burden of showing that you would not otherwise have been employed at the time of reinstatement as requested in order to deny restoration to employment. If you were hired for a specific term or to perform a specific project, the District has no obligation to restore you if the employment term or project is over and the District would not otherwise have continued to employ you. Q. If you exercise your FMLA leave rights, how are you protected? The District will not interfere with the exercise of an employee's rights to FMLA leave, not only by not refusing to authorize FMLA leave, but by not discouraging an employee from utilizing such leave. The District may not discriminate against an employee who uses FMLA leave. If you have concerns as to the exercise of your legal rights or questions as to the FMLA, please contact the Office of Employee Services. If an employee believes that his/her rights under FMLA have been violated, the employee may file or have another person file on his/her behalf, a written complaint with the Wage and Hour Division of the Department of Labor or the Department of Workforce Development-Equal Rights Division. Q. Under what circumstances can the District refuse to provide FMLA or reinstatement to eligible employees? 1. If an employee fails to give timely advance notice when the need for FMLA leave is foreseeable, the District may deny the taking of FMLA leave until fifteen days after the date the employee provides notice to the District. 2. If an employee fails to provide in fifteen calendar days a requested Health Care Provider Certification to substantiate the need for foreseeable FMLA leave due to a serious health condition, the District may deny FMLA leave until the employee submits this Certification. If an employee on an unforeseen or emergency leave fails to provide the District with a completed Certification within fifteen days of receipt of the Certification, the District may deny the employee's leave or the continuation of leave. 3. If an employee fails to provide a requested fitness for duty certification to return to work, the District may deny reinstatement until the employee submits this certificate. 4. An employee has no greater right to reinstatement or to other benefits and conditions of employment than if the employee had been continuously employed during the FMLA leave period. However, an employee will not accrue any additional benefits or rights during leave. 5. If an employee unequivocally advises the District that he/she does not intend to return to work, the employment relationship is terminated and the employee's entitlement to reinstatement, continued leave and employment benefits ceases. The District may require an employee on FMLA leave to report periodically on the employee's status and intention to return to work. 6. An employee who fraudulently obtains FMLA leave from the District is not protected by FMLA job restoration or maintenance of health benefits provisions. Further, any employee who fraudulently obtains FMLA leave will be subjected to discipline, up to and including discharge. 12

Family and Medical Leave 13 Q. How does the Family and Medical Leave Laws affect state laws, District master contracts and personnel policies? Nothing in the law supersedes any greater benefits already required by state law or provided by the District. 13

Family and Medical Leave 14 FMLA RELATED FORMS 14

EMPLOYEE VACATION/LEAVE REQUEST/REPORT ======================================================================== -COMPLETED BY THE EMPLOYEE- Employee Name (Please print) Employee ID number School/Location TYPE OF ABSENCE/LEAVE REQUESTED Date of Hire Medical/Sick Leave (If >3 days, complete box below) Leave without pay Mentor/Mentee Shared Release Personal Leave Athletics/Student Activities Building Meeting Bereavement Leave/Funeral Integration Day District Meeting Jury Duty IEP Other Vacation Conference/Workshop Beginning Date Through or End Date Total #Days/Hours Full Day Half Day AM/PM Full Day Half Day AM/PM For Paid Personal Leave I certify that the reason is of a personal nature and meets the specifications stated in the leave section of my employee group s master contract or personnel policies. For FMLA Leave (more than 3 days) Medical condition (self) Adoption/Birth of Child Care of family member undergoing medical (Maximum FMLA 12 weeks) treatment, recuperation, therapy, is otherwise in Care of child/parent/spouse with serious health condition outpatient status, or is otherwise on the (Maximum FMLA 12 weeks) temporary disability retired list, for a serious injury or illness (maximum 26 weeks) Dates(s) Requested: Beginning Through (end date) PAID/UNPAID: With Pay Without Pay HOW PAID?: Reimbursable Leave days/hours Vacation days/hours Comp Time (attach documentation) days/hours Personal Leave days/hours Employee Signature Date ================================================================================= Principal/Supervisor: Recommended Not Recommended Reason: Signature Date ================================================================================= -EMPLOYEE SERVICES DEPARTMENT ACTION- Approved Disapproved Reason: Date: COPIES TO: BENEFITS PAYROLL WORKSITE EMPLOYEE 15

Health Care Provider s Certification of Employee s Serious Health Condition (Family and Medical Leave Act) Employer name and contact: Employee s job title: Regular work schedule: Employee s essential job functions: Check if job description is attached: SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 20 C.F.R. 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. 825.305(b). Your name: First Middle Last SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as lifetime, unknown, or indeterminate may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page. Provider s name and business address: Type of practice / Medical specialty: Telephone: ( ) Fax:( ) Page 1 -CONTINUED ON NEXT PAGE- Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 16

PART A: MEDICAL FACTS 1. Approximate date condition commenced: Probable duration of condition: Mark below as applicable: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes. If so, dates of admission: Date(s) you treated the patient for condition: Will the patient need to have treatment visits at least twice per year due to the condition? No Yes. Was medication, other than over-the-counter medication, prescribed? No Yes. Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? No Yes. If so, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? No Yes. If so, expected delivery date: 3. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the employee s essential functions or a job description, answer these questions based upon the employee s own description of his/her job functions. Is the employee unable to perform any of his/her job functions due to the condition: No Yes. If so, identify the job functions the employee is unable to perform: 4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment): Page 2 -CONTINUED ON NEXT PAGE- Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 17

PART B: AMOUNT OF LEAVE NEEDED 5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? No Yes. If so, estimate the beginning and ending dates for the period of incapacity: Begins Ends 6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee s medical condition? No Yes. If so, are the treatments or the reduced number of hours of work medically necessary? No Yes. Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Estimate the part-time or reduced work schedule the employee needs, if any: hour(s) per day; days per week from through. 7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? No Yes. Is it medically necessary for the employee to be absent from work during the flare-ups? No Yes. If so, explain: Based upon the patient s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days): Frequency: times per week(s) month(s) Duration: hours or day(s) per episode Page 3 -CONTINUED ON NEXT PAGE Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 18

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER. Signature of Health Care Provider Date Please print Health Care Provider s name on line above Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 19

Certification of Health Care Provider for Family Member s Serious Health Condition (Family and Medical Leave Act) Employer name and contact: SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II and the Employee Name and Patient Name in Section III before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. 825.313. You must return this form within 15 calendar days to the contact listed above. Your name: First Middle Last Name of family member for whom you will provide care: First Middle Last Relationship of family member to you: If family member is your son or daughter, date of birth: Describe care you will provide to your family member and estimate leave needed to provide care: Employee Signature Date Print Name Page 1 -CONTINUED ON NEXT PAGE- Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 20

SECTION III: For Completion by the HEALTH CARE PROVIDER RE: Employee Name Patient s Name INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as lifetime, unknown, or indeterminate may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the patient needs leave. Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last page. Provider s name and business address: Type of practice / Medical specialty: Telephone: ( ) Fax:( ) 1. Approximate date condition commenced: Probable duration of condition: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? Yes No. PART A: MEDICAL FACTS If so, dates of admission: Date(s) you treated the patient for condition: Was medication, other than over-the-counter medication, prescribed? treatment visits at least twice per year due to the condition? Yes No. Will the patient need to have Yes No. Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? Yes No If so, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? Yes No. If so, expected delivery date: 3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment): Page 2 -CONTINUED ON NEXT PAGE - Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 21

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care: 4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? Yes No. Estimate the beginning and ending dates for the period of incapacity: During this time, will the patient need care? Yes No. Explain the care needed by the patient and why such care is medically necessary: 5. Will the patient require follow-up treatments, including any time for recovery? Yes No. Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Explain the care needed by the patient, and why such care is medically necessary: 6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? Yes No. Estimate the hours the patient needs care on an intermittent basis, if any: hour(s) per day; days per week from through. Explain the care needed by the patient, and why such care is medically necessary: Page 3 -CONTINUED ON NEXT PAGE- Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 22

7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities? Yes No. Based upon the patient s medical history and your knowledge of the medical condition, estimate the frequency of flareups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days): Frequency: times per week(s) month(s) Duration: hours or day(s) per episode Does the patient need care during these flare-ups? Yes No. Explain the care needed by the patient, and why such care is medically necessary: ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER. Print Name of Health Care Provider here: Signature of Health Care Provider Date Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 23

Challenge Inspire Support MIDDLETON-CROSS PLAINS AREA SCHOOL DISTRICT FITNESS TO RETURN TO WORK FORM 1. Patient's name: 2. Date on which patient may resume work: 3. Based upon the physical requirements listed in the Functional Analysis of the position (see attached), the patient is: Fully Capable or Limited in performing all outlined requirements (check which applies). 4. List the requirements of the position which the patient would not be capable of performing. In responding, please include restrictions necessary to insure the patient does not pose a threat of harm to her/himself or others. Signature of Physician or Practitioner Type of Practice or Field of Specialty Printed name of Physician or Practitioner Date 24 Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us

Functional Capacities Form Patient Name: Date of Injury: Dates of Evaluation: Diagnosis: 1. The following restrictions are temporary permanent. 2. The patient is capable of a return to work on for hours/day. (Date) ITEM Lifting (lbs) PERCENT OF DAY (Based on 8 hour day) 0 1-5 6-33 34-66 67-100 Never Rare Occasionally Frequently Constantly Restrictions And Recommendations Floor to Waist Lift Waist to Shoulder Lift Horizontal Lift Bilateral Push force Bilateral Pull force Two hand carry Left hand carry Right hand carry Standing Tolerance Sitting Tolerance Please return this form to Lori Krug, Benefits Specialist in the Employee Services Department at: Fax 608-836-3571 or Mail 7106 South Ave., Middleton WI 53562 25

Family and Medical Leave 26 MILITARY FMLA FORMS 26

Certification of Qualifying Exigency (need) For Military Family Leave (Family and Medical Leave Act) Employer name: Middleton-Cross Plains Area School District Contact Information: Lori Krug, Benefits Specialist INSTRUCTIONS to the EMPLOYEE: Please complete fully and completely. The FMLA permits an employer to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a qualifying exigency. Several questions in this section seek a response as to the frequency or duration of the qualifying exigency. Be as specific as you can; terms such as unknown, or indeterminate may not be sufficient to determine FMLA coverage. Your response is required to obtain a benefit. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at least 15 calendar days to return this form to your employer. Your Name: First Middle Last Name of covered military member on active duty or call to active duty status in support of a contingency operation: First Middle Last Relationship of covered military member to you: Period of covered military member s active duty: A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a covered military member s active duty or call to active duty status in support of a contingency operation. Please check one of the following: A copy of the covered military member s active duty orders is attached. Other documentation from the military certifying that the covered military member is on active duty (or has been notified of an impending call to active duty) in support of a contingency operation is attached. I have previously provided my employer with sufficient written documentation confirming the covered military member s active duty or call to active duty status in support of a contingency operation. PART A: QUALIFYING REASON FOR LEAVE 1. Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you are requesting leave): Page 1 Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 27

2. A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes any available written documentation which supports the need for leave. Such documentation may include a copy of a meeting announcement for informational briefings sponsored by the military, a document confirming an appointment with a counselor or school official, or a copy of a bill for services for the handling of legal or financial affairs. Available written documentation supporting this request for leave is attached. Yes No None Available PART B: AMOUNT OF LEAVE NEEDED 1. Approximate date exigency commenced: Probable duration of exigency: 2. Will you need to be absent from work for a single continuous period of time due to the qualifying exigency? Yes No If so, estimate the beginning and ending dates for the period of absence:. 3. Will you need to be absent from work periodically to address this qualifying exigency? Yes No. Estimate schedule of leave, including the dates of any scheduled meetings or appointments: Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time (i.e., 1 deployment-related meeting every month lasting 4 hours): Frequency: times per week(s) month(s) Duration: hours day(s) per event. PART C: If leave is requested to meet with a third party (such as to arrange for childcare, to attend counseling, to attend meetings with school or childcare providers, to make financial or legal arrangements, to act as the covered military member s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and sufficient certification includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either the telephone or fax number or email address of the individual or entity). This information may be used by your employer to verify that the information contained on this form is accurate. Name of Individual: Title: Organization: Address: Telephone: ( ) Fax: ( ) Email: Middleton-Cross Plains Area School District, 7106 South Ave., Middleton, WI 53562 (608) 829-9000 Fax (608) 836-1536 www.mcpasd.k12.wi.us 28