E3-LWOP Pending Receipt of SHCC
[DATE]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
Personnel Number
Dear [EMPLOYEE]:
Please review the information on the enclosed Notice of Eligibilityas it explains why yourabsence does not qualify as leave under the Family and Medical Leave Act (FMLA) and cannotbe approved.
To determine if your absence beginning [DATE] can be approved as extended leave without pay (LWOP) absence, you must have the healthcare provider complete the enclosed Serious Health Condition Certification form and return itby [DATE]. In addition, you must submit a written request for extended LWOP absence.
[You must provide proof of the date of birth or court documents for adoption or foster care placement to us by [DATE]. To enroll a dependent in health coverage, contact [the HR Service Center at 1.866.377.2672 or your local Human Resource Office if your agency is not served by the HR Service Center] for the forms to complete.]
As of [DATE], you will have limited return to work rights if your absence continues beyond this date. Return rights are usually to a vacant position in the same or equivalent classification to which there are no seniority claims and which the agency intends to fill. Rights can vary by union. Therefore, if you are medically released to return to work after [DATE], do not report to work. Instead, notify this office so that we can determine if there is a position available. If a position is not available, you will remain on extended LWOP absence until a position becomes available. If no position becomes available, your employment with the commonwealth will end at the exhaustion of the extended LWOP absence entitlement.
[Your entitlement to health care benefits and group life insurance [expired OR will expire] at midnight on [LAST DATE WITH BENEFITS – 91st DAY][,should you continue your absence beyond this date]. The enclosed Important Notice Regarding Health and Life Insurance Benefits provides information about benefits while on a leave without pay absence.]
If you do not act by [DATE] as a result of this letter, you should be aware that you may loseyour rights to extended LWOP absence. For employees who have no paid leave and who do not followthe instructions, the absence may be charged to absence without leave (AW), which mayinclude disciplinary action up to and including termination.
If you have any questions, please contact me at [EMAIL] or [PHONE NUMBER]. PA Relay Service for the deaf or hard of hearing is available at 711 or 1.800.654.5988.
Sincerely,
Xxxx
For XXX,
Secretary of XXX
Enclosures:Notice to Employees and Important Notice Regarding Health Benefits
Eligibility Notice
Serious Health Condition Certification and Essential Functions
Adult Child Certification of Disability
cc:Bureau Director
Supervisor (including copy of FMLA/SPF Checklist for Supervisors)
Time Advisor
Labor Relations Coordinator
Disability Services Coordinator
Timekeeper
This action does not indicate and should not be interpreted to indicate that you are regarded by the Commonwealth as having a disability as defined by the ADA.
Version 1.24.2017