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COPY THESE FORMS ONTO COMPANY STATIONARY
REQUEST FOR FAMILY AND MEDICAL LEAVE OF ABSENCE
Employees who have worked for at least 1,250 hours
during the 12-month period immediately prior to the request for leave
are eligible for leave.
Name: _____________________________ Employee Number:
_______________
Department: _________________________ Hire Date:
______________________
TYPE OF LEAVE REQUESTED
(Check one box)
[ ] Employee Medical Leave of Absence
[ ] Extension of Employee Medical Leave of
Absence
Dates of prior approved Medical Leaves are:
__________________ to __________________
[ ] Family Medical Leave of Absence
[ ] Extension of Family Medical Leave of
Absence
Dates of prior approved Family Medical Leave are:
__________________ to _________________
[ ] Leave to care for newborn or adopted
child or a child placed (via formal government procedures) for foster
care
The Leave (or extension) requested will begin on
______________ and end on ______________. If the request is for multiple
days off for recurring medical treatments of a child, parent, or spouse,
or for your own medical treatments, specify dates requested:
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REASON FOR LEAVE
I request a family leave of absence for: (Check one box)
[ ] My personal SERIOUS health condition
[ ] Birth of my child
[ ] Adoption for a child by me
[ ] Placement (by the government) of a child
with me for foster care
[ ] Serious health condition of my child
[ ] Serious health condition of my parent
[ ] Serious health condition of my spouse
File: 1 copy to employee; original in personnel file
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Combined Leave Policy
This form is to be completed by any employee who is
requesting leave and whose spouse is also employed here.
Check the leave being requested:
_____ Family leave to care for a newly arrived child
_____ Family Medical Leave to care for a parent with a
serious health condition
Circle Yes or No
Yes
No My spouse is also employed here.
Spouse Name: _________________________ Employee Number:
_______________
Department: ___________________________ Hire Date:
______________________
I certify by my signature that I have read and agree to
abide by this policy:
In any case in which a husband and wife are:
(a) Both employed at this company and,
(b) Both entitled to leave,
(c) If the leave is taken for the birth or adoption of a
child or to care for the serious health condition of a parent,
Then the aggregate number of workweeks of leave that
both may take is limited to 12 workweeks during any 12-month period.
If there is a change in our circumstances above, I will
notify the Company immediately.
Date: ________________________________ Name (Print)
_____________________
Employee Number: _____________________ Name (Sign)
_____________________
File: 1 copy to employee; original in personnel file
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Insurance Premium Recovery Authorization Form
I certify by my signature that I have read and
understand the policy covering Insurance Premium Recovery.
I acknowledge the Company’s legal right to recover the
cost of any premium paid by it to maintain my coverage in group health
benefits during any period of unpaid leave.
1. I fail to return from leave at the expiration of the
leave to which I am entitled; and
2. The reason I fail to return to work is not one of the
following:
A. The continuation, recurrence, or onset of a serious
health condition that entitles me to leave to care for a child, parent
or spouse with a serious health condition, or if I am unable to perform
the functions of my position due to my own serious health condition; or,
Date: ________________________________ Name (Print)
_____________________
Employee Number: _____________________ Name (Sign)
_____________________
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INSURANCE PREMIUM REIMBURSEMENT AGREEMENT
I certify by my signature that I have read and agree to
do the Policy on Insurance Premium Reimbursement.
If I fail to return from leave, for any reason other
than 2-A or 2-B above, I agree to arrange for a mutually acceptable
schedule to reimburse the Company for the cost of any premium paid by it
to maintain my coverage in group health benefits during any period of
unpaid leave taken by me.
Date: ________________________________ Name (Print)
_____________________
Employee Number: _____________________ Name (Sign)
_____________________
1 copy to employee; original in personnel file
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Leave Certification Requirements
SECTION I
To request leave for the care of a child, parent, or
spouse with a serious health condition
I have attached a certification from the health care
provider who is treating my child, parent, or spouse. The certification
includes the following:
1. The date on which the condition commenced
2. The probable duration of the condition
3. The appropriate medical facts within the knowledge of
the health care provider regarding the condition
4. An estimate of the time needed to care for the person
involved (including any recurring medical treatment)
5. A statement that the condition warrants my
participation to provide care.
SECTION II
To request leave for the care of any employee’s own
personal serious health condition
I have attached certification from the health care
provider who is treating my own serious health condition. The
certification includes the following:
1. The date on which my condition commenced
2. The probable duration of my condition
3. The appropriate medical facts within the knowledge of
the health care provider regarding my condition
4. A statement that I am unable to perform the functions
of my position due to my condition
SECTION III
Additional certification requirements for intermittent
leave or for leave on a reduced leave schedule
In addition to the foregoing certifications from the
health care provider involved, I have attached additional information
from the health care provider:
A. Leave for the employee
1. A statement of medical necessity for my intermittent
leave or reduced leave schedule and the expected duration of the
schedule.
2. A listing of the dates of my planned medical
treatment and the duration of the treatment(s).
B. Leave to care for a son, daughter, spouse or parent
1. A statement attesting to the necessity of
intermittent leave or reduced leave for me to provide care or to assist
in their recovery.
2. An estimate of the expected duration and schedule of
my intermittent or reduced leave.
_____________________________________________________________________________.
I certify by my signature that I have read and
understand this certification policy.
Date: ________________________________ Name (Print)
_____________________
Employee Number: _____________________ Name (Sign)
_____________________
File: 1 copy to employee; original in personnel file
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Certification of Physician or Practitioner
(Family and Medical Leave Act of
1993)
1. Employee’s
Name:________________________________________________
2. Patient’s Name (If other than
employee):________________________________
3.
Diagnosis:_______________________________________________________
4. Date condition commenced: 5. Probable duration of
condition:________________
6. Regimen of treatment to be presented (Indicate number
of visits, general nature and duration of treatment, including referral
to other provider of health services. Include schedule of visits or
treatment if it is medically necessary for the employee to be off work
on an intermittent basis or to work less than the employee’s normal
schedule of hours per day or days per week):
a. By Physician or Practitioner:
b. By another provider of health services, if referred
by Physician or Practitioner:
IF THIS CERTIFICATION RELATES TO CARE FOR THE EMPLOYEE’S
SERIOUSLY-ILL FAMILY MEMBER SKIP ITEMS 7, 8, AND 9 AND PROCEED TO ITEMS
10 THRU 14. OTHERWISE CONTINUE BELOW.
Please check Yes or No in the boxes below, as
appropriate.
Yes No
7. [ ]
[ ] Is inpatient hospitalization of the employee required?
8. [ ]
[ ] Is employee able to perform work of any kind? (If
"No", skip Item 9.)
9. [ ]
[ ] Is employee able to perform the functions of employee’s
position? (Answer after reviewing statement from employer of essential
functions of employee’s position, or, if none provided, after
discussing with employee.)
15. Signature of licensed
Physician___________________________________:
16: Date:____________________
17. Type of Practice (Field of Specialization, if
any):______________________
FOR CERTIFICATION RELATING TO CARE FOR THE EMPLOYEE’S
SERIOUSLY-ILL FAMILY MEMBER COMPLETE ITEMS 10 THRU 14 BELOW AS THEY
APPLY TO THE FAMILY MEMBER.
Yes No
10. [ ]
[ ] Is inpatient hospitalization of the family member
(patient) required?
11. [ ]
[ ] Does (or will) the patient require assistance for basic
medical, hygiene, nutritional needs, safety or transportation?
12. [ ]
[ ] After review of the employee’s signed statement (See
Item 14 below), is the employee’s presence necessary or would it be
beneficial for the care of the patient? (This may include psychological
comfort).
13. Estimate the period of time care is needed or the
employee’s presence would be
beneficial:__________________________________________________
ITEM 14 IS TO BE COMPLETED BY THE EMPLOYEE NEEDING FAMILY LEAVE.
14. When Family Leave is needed to care for a
seriously-ill family member, the employee shall state the care they will
provide and an estimate of the time period during which this care will
be provided, including a schedule if leave is to be taken intermittently
or on a reduced leave schedule:
Employee
Signature:______________________________________
Date:____________________________
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