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HomeMy WebLinkAboutFMLA EMPLOYEE CERTIFICATION 11 2010.docxEMPLOYEE SELF CERTIFICATION OF REQUEST FOR FAMILY MEDICAL LEAVE-ELIGIBLE TIME OFF I have read the information on page 2 of this form. I am going to be gone from work for a reason which is among the “qualifying leaves” under the FMLA and, therefore, I request FMLA-eligible leave for the following purpose: the birth of a child, or the placement of a child for adoption or foster care; a serious health condition that I need care for; a serious health condition affecting my: ( spouse, ( child, ( parent, for which I am needed to provide care; a serious health condition that makes me unable to perform the functions of my job; a qualifying exigency arising out of the fact that my: ( spouse, ( son, ( daughter, or ( parent, is a covered military member on “covered active duty” (active duty or call to active duty status pursuant to any law that allows reserve service members to be called to active duty in support of a contingency operation. This includes military retirees, but does not include members of the regular armed forces.); to care for a covered service member with a serious injury or illness who is my: ( spouse, ( son, ( daughter, ( parent, or ( next of kin (military caregiver leave). 2. The specific reason for my leave request is: 3. My anticipated leave dates are: From:_________________________ To: _______________________ 4a. I am requesting the following leave schedule: ( Full time Leave ( Intermittent Leave (leave taken in separate blocks of time for a single illness or injury) ( Reduced Schedule Leave (a change in the employee’s schedule for a period of time, normally from full-time to part-time.) 4b. If Intermittent or Reduced Schedule is involved, in the space below, describe the proposed leave schedule. The City will work with the employee to identify a schedule that will work for both parties. 5. I understand that: Upon receipt of this form, Human Resources will send me additional information regarding my rights and responsibilities under City Policy and under the Family and Medical Leave Act; This time off will be counted against my annual Family and Medical Leave allotment; The City reserves the right to confirm my eligibility for leave under the FMLA.  If confirmation of the eligibility for leave is required by the City, I will receive a notice from the Human Resources Department and will be given no less than 15 days to provide certification of eligibility from my health care provider.    In signing this form, I request this time off under the conditions above, and certify that the reasons I have given for requesting this leave are true. I understand that giving false information regarding the need for leave, including leave under the Family and Medical Leave Act, may be cause for disciplinary action up to and including termination. Employee Name: _______________________________________ Date: _____________________________________ Print/Type name: _______________________________________ Information Regarding Eligibility for Leave under the Family and Medical Leave Act The Family and Medical Leave Act (FMLA) entitles eligible employees to take unpaid (1), job-protected leave for specified reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. Eligible employees include City employees who: Have been employed by the City for at least 12 months, and Have been employed for at least 1,250 hours of service during the 12-month period immediately preceding the commencement of the leave; and who Are not ‘key’ employees as defined in the Family Medical Leave Act (29 CFR. § 825.217) Eligible employees are entitled to: 1. Twelve workweeks of leave in a 12-month period for: the birth of a child and to care for the newborn child within one year of birth; the placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement; to care for the employee’s spouse, child, or parent who has a serious health condition(2); a serious health condition(2) that makes the employee unable to perform the essential functions of his or her job; any “qualifying exigency” (3) arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on “covered active duty;” or 2. Twenty-six workweeks of leave during a single 12-month period to care for a covered service member with a serious injury or illness who is the spouse, son, daughter, parent, or next of kin to the employee (military caregiver leave). (1) Generally, FMLA leave is unpaid leave. However the FMLA permits an eligible employee to choose to substitute accrued paid leave for FMLA leave. If an employee does not choose to substitute accrued paid leave, the employer may require the employee to substitute accrued paid leave for unpaid FMLA leave. The term “substitute” means that the paid leave provided by the employer, and accrued pursuant to established policies of the employer, will run concurrently with the unpaid FMLA leave. (2) Under the FMLA, a “Serious health condition” means an illness, injury, impairment, or physical or mental condition that involves either: Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical-care facility, including any period of incapacity (i.e., inability to work, attend school, or perform other regular daily activities) or subsequent treatment in connection with such inpatient care; or Continuing treatment by a health care provider, which includes: (1) A period of incapacity lasting more than three consecutive, full calendar days, and any subsequent treatment or period of incapacity relating to the same condition, that also includes: treatment two or more times by or under the supervision of a health care provider (i.e., in-person visits, the first within 7 days and both within 30 days of the first day of incapacity); or one treatment by a health care provider (i.e., an in-person visit within 7 days of the first day of incapacity) with a continuing regimen of treatment (e.g., prescription medication, physical therapy); or (2) Any period of incapacity related to pregnancy or for prenatal care. A visit to the health care provider is not necessary for each absence; or (3) Any period of incapacity or treatment for a chronic serious health condition which continues over an extended period of time, requires periodic visits (at least twice a year) to a health care provider, and may involve occasional episodes of incapacity. A visit to a health care provider is not necessary for each absence; or (4) A period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. Only supervision by a health care provider is required, rather than active treatment; or (5) Any absences to receive multiple treatments for restorative surgery or for a condition that would likely result in a period of incapacity of more than three days if not treated. “ (3) Military-related qualifying exigencies may include, but are not limited, to time off: (1) To address any issue arising from the fact that a covered military member is notified of an impending call or order to active duty in support of a contingency operation 7 or less calendar days prior to the date of deployment; (2) To attend Military events and related activities; 3) To address Childcare and school issues arising from the active duty status of a covered military member; (4) to make Financial and legal arrangements; (5) For Counseling; (6) For Rest and Recuperation; (7) To attend Post-deployment activities and to address issues that arise from the death of a covered military member while on active duty status, such as meeting and recovering the body of the covered military member and making funeral arrangements; any (8) Any other events the employer and employee agree qualify as an exigency.