FMLA MATERNITY LEAVE APPROVAL LETTER
Date:______
To:______
From:______
We have reviewed your request for leave under the Family and Medical Leave Act (FMLA)due to your disability as a result of pregnancy and related conditions including childbirth, including any time following the disability for baby bonding, if available.
We received your most recent medical certification on ______and determined your FMLA leave request is approved based on the date your healthcare provider designated you as disabled due to the pregnancy.
Leave Duration (check applicable option)
The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. Based on the information you have provided to date, we are providing the following information about the amount of time that will be counted against your leave entitlement:
___Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will be counted against your leave entitlement: ______
___Because the leave you will need will be intermittent or unscheduled, it is not possible to provide the hours, days, or weeks that will be counted against your FMLA entitlement at this time.
Please be advised (check allthat apply):
___You have requested to use paid leave during your FMLA leave. Any paid leave taken for this reason will count against your FMLA leave entitlement.
___We are requiring you to substitute or use paid leave during your FMLA leave.
___You will be required to present a fitness-for-duty certificate to be restored to employment. If such certification is not timely received, your return to work may be delayed until certification is provided. A list of the essential functions of yourposition ____ [is/is not] attached. If attached, the fitness-for-duty certification must address your ability to perform these essential functions.
Previous Leave Taken
You previously have used______[number of days/hours]of family and medical leave during the current 12-month period and thus the total remaining family and medical leave available to you is ______[number of days/hours].
Return to Work
According to the information received, you should be able to return to work on ______[date].
If you are unable to return to work at that time, you must contact ______[contact name] at ______[phone number or email].
You are required to return to work at the end of the approved FMLA leave. If you have need for additional FMLA leave (not to exceed 12 weeks), you should provide continued medical certification. You may also be eligible for other pregnancy disability leave, baby bonding leave, or other pregnancy-, birth-, or placement-related leave under state law.
Use of Vacation
During your family and medical leave, you may take any accrued and unused vacation hours. You currently have ______hours available to you.
Please advise your supervisor if you wish to use any of your vacation time during your leave.
Use of Sick Leave
Company policy______[allows/requires] use of paid sick leave during family and medical leave. You currently have_____hours of accrued sick leave. The sick time_____ [may/will] be paid out beginning on yourfirst day of absence.
Use of SDI
If you are eligible for state disability insurance (SDI), your SDI benefits and sick leave pay will be coordinated so that your SDI/sick leave payments do not exceed your normal rate of pay.
Continued Health Benefits
Under state and federal family and medical leave, you are eligible for continued health benefits during your FMLA leave for a maximum of 12 weeks. State laws may provide for other pregnancy disability benefits. For example, under California law, employees on pregnancy disability leave will be allowed to continue to participate in group health coverage for up to a maximum of four months of pregnancy disability leave (if such insurance was provided before the leave was taken) on the same terms as if the employee had continued to work.
Your continuation of health benefits will begin on______[date]. If you currently contribute to the payment of benefits, you must continue to do so while on leave. Your payment in the amount $______is due on or before______[date, i.e.15th of each month].
Option: The Company’s health plan has a grace period for late payments. If your payment is more than _____ days late, your benefits will cease and you will receive COBRA information.
Send payments to:
Representative: ______
Company Name: ______
Address: ______
City State ZIP Code: ______
Your medical benefit coverage will end on______[date]. You may be eligible for continued COBRA coverage.
Remember that because you are absent due to your own illness or injury, you must provide the Company with a medical release to work form or certification from your doctor of continued disability on or before: ______[day after the prior certification expires].
If you have questions about FMLA or other benefits, please contact:
Name: ______
Phone Number: ______
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