FAMILY AND MEDICAL LEAVE REQUEST

Name ______Program ______

Hire Date: ______

Status:  Full Time-Career  Part Time-Career  Part Time-Non Career

I REQUEST A FAMILY MEDICAL LEAVE FOR ONE

OR MORE OF THE FOLLOWING REASONS:

 Birth of a child, or the placement of a child for adoption or foster care.

 A serious health condition affecting my  Spouse  Child  Parent for which I am needed to provide care.

 For a serious health condition that makes me unable to perform the essential functions of my job.

This leave to begin on ______and will continue until on or about______.

Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period revolving period calculated from the last day you took FMLA. Your health and/or other benefit deductions must be maintained during any period of unpaid leave under the same conditions as if you continued to work, and you must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from leave. If you do not return to work following FMLA leave for a reason other than : (1) the continuation, recurrence, or onset of a serious health as documented by a doctors notification; or (2) other circumstances beyond your control, you may be required to reimburse Southwest Behavioral Health Center for our share of health insurance premiums paid on your behalf during your FMLA leave.

This is to inform you that:

  1. You are  eligible  not eligible for leave under the Family Medical Leave Act (FMLA).
  1.  You will need to furnish medical certification of a serious health condition within 15 days, or this may delay the commencement of your leave until the certification is submitted.
  1.  You will be required to substitute accrued paid leave for unpaid FMLA leave.
  1. Premiums you normally pay for supplemental health insurance, AFLAC, etc., will continue during the period of FMLA leave. Arrangements for payment have been discussed with the payroll office, and it is agreed that you will make premium payments as follows:

______

  1.  Proposed intermittent leave schedule, if applicable, subject to approval.

Have you taken a family or medical leave in the past 12 months?  No  Yes # of days______

READ AND COMPLETE BACK OF FORM

 You will be required to present a fitness-for-duty certificate prior to being restored to employment. If such certification is not received; your return to work may be delayed until certification is provided.

NOTE: I understand that a failure to return to work at the end of my leave period may be treated as a resignation unless an extension has been agreed upon, in writing, and approved by the Executive Director. If I do not return from this medical leave, I will be responsible to repay SouthwestBehavioralHealthCenter for their share of any health insurance premiums paid on my behalf during the FMLA leave.

Signature: ______Date: ______

Employee

______Date: ______Immediate Supervisor

APPROVED BY:

Executive Director

Original: Human Resource Office

Copy sent to employee: ______

FMLA Form Updated 10-08