COPY ONTO COMPANY STATIONARY

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: ______________________

(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 state 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:

_____________________________________________________________________________.

I request a family leave of absence for the following reason:

(Check one box)

[ ] My personal serious health condition

[ ] Birth of my child

[ ] Adoption for a child by me

[ ] Placement (by the state) 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

This form is to be completed by any employee who is requesting leave and whose spouse is also employed here.

_____ Family leave to care for a newly arrived child

_____ Family Medical Leave to care for a parent with a serious health condition

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

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) _____________________

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

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.

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

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

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.

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 Physician or Practitioner:

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: