Note: This Section May Not Apply to Company Nameat This Time

Memorandum / Letter / Form Index

Note: This section may not apply to Company Nameat this time.

Family Medical Leave Index

Completed by Company Representative

The Family and Medical Leave Act Fact Sheet

Federal fact sheet to determine if FMLA applies to your company.

Industrial Accident FMLA Notification

To be sent whenever an industrial accident or illness results in time loss from work.

FMLA Acceptance / Denial

To be sent after you have reviewed the request for leave and any appropriate medical information.

Received Request

*To be sent after receipt of request for leave to give provisional acceptance allowing for more time to review request.

Received Request / Send Certification of Health Care Provider

To be sent after receipt of request for leave giving provisional acceptance and requesting the Certification of Health Care Provider. (attach Certification of Health Care Provider Form)

Received Request / Denial

To be sent after a thorough review of the request for leave and all appropriate medical information.

MCCF10/22/2018

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FAMILY AND MEDICAL LEAVE ACT INFORMATION

EMPLOYEE RIGHTS AND RESPONSIBILITIES

UNDER THE FAMILY AND MEDICAL LEAVE ACT

MCCF10/22/2018

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FAMILY AND MEDICAL LEAVE ACT INFORMATION

Basic Leave Entitlement

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:

• For incapacity due to pregnancy, prenatal medical care or child birth;

• To care for the employee’s child after birth, or placement for adoption or foster care;

• To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition; or

• For a serious health condition that makes the employee unable to perform the employee’s job.

Military Family Leave Entitlements

Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings.

FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered servicemember during a single 12-month period. A covered servicemember is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the servicemember medically unfit to perform his or her duties for which the servicemember is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary disability retired list.

Benefits and Protections

During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms.

Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.

Eligibility Requirements

Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 50 employees are employed by the employer within 75 miles.

Definition of Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities.

Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment.

Use of Leave

An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis.

Substitution of Paid Leave for Unpaid Leave

Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer’s normal paid leave policies.

Employee Responsibilities

Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures.

Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave.

Employer Responsibilities

Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees’ rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility.

Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee’s leave entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notify the employee.

Unlawful Acts by Employers

FMLA makes it unlawful for any employer to:

• Interfere with, restrain, or deny the exercise of any right provided under FMLA;

• Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.

Enforcement

An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer.

FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights.

FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text of this notice. Regulations 29 C.F.R. § 825.300(a) may require additional disclosures.

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FAMILY AND MEDICAL LEAVE ACT INFORMATION

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Family and Medical Leave of Absence (FMLA) Request Form

FOR EMPLOYEE TO COMPLETE

Employee’s Name: Employee ID No.:

Job Title/Division:

Expected Leave Start Date: Expected Leave End Date:

PURPOSE OF LEAVE:

1. Birth of my child

2. Adoption of my child

3. Foster care placement of a child in my care

4. Care of an immediate family member (spouse, parent, or child) with a serious health condition

Name of family member:

Relationship to employee:

5. Employee’s own serious health condition

6. Other reason:

REQUEST FOR REDUCED OR INTERMITTENT LEAVE:

Please state your need for reduced or intermittent leave and a suggested schedule of leave time away from your job (attach

additional information to this form if necessary).

MEDICAL CERTIFICATION:

Company Name generally requires that medical conditions be substantiated by a certification from a health care provider to verify

the employee (or immediate family member) has a serious health condition which qualifies for coverage under the FMLA. The

Certification of Health Care Provider Form is a separate document available from your ER/HR representative. Approval of any

medically-related leave may be subject to the information provided by the health care provider.

PAYMENT OF HEALTH CARE AND OTHER BENEFITS DURING AN APPROVED LEAVE OF ABSENCE:

I agree to continue paying my share of premiums by direct payment for any medical, dental, and/or vision coverage which I am

enrolled in prior to taking a leave of absence. I understand that I will be notified of the premium amount separately and will

submit my payment promptly to the company to continue my coverage’s. I understand that the company has the right to cancel

my benefits if I fail to make the required premium payments. If my coverage’s lapse, I understand that the company will reinstate

any coverage’s I had without restriction once I return to active employment.

Employee SignatureDate

FOR EMPLOYER USE ONLY

Based on review of this form and the medical certification form (if applicable), leave is ELIGIBLE under the FMLA and will be

charged against employee’s entitlement.

Based on review of this form and the medical certification form (if applicable), leave is NOT ELIGIBLE under the FMLA and will

not be counted toward the employee’s entitlement. Leave is approved under the location’s leave-of-absence policy and is subject to

the guidance set forth in that policy.

Leave of absence is not covered by federal or state law or company policy and is therefore not approved.

Company RepresentativeDate

MCCF10/22/2018

FRQST

RE:Family/Medical Leave Request

Patient:

Employer:

Employee ID No.:

Date / Absence(s):

Dear :

This letter is to inform you that we have received information that you were involved in an industrial accident. Under your employer’s family medical leave plan, workers’ compensation and family medical leave run concurrently, therefore the absence(s) listed above will be counted against your annual twelve week entitlement to family medical leave. Additionally, any further time loss due to this injury will also be counted against your remaining Family Medical Leave entitlement, up to the total of 480 hours.

You have the right under the Federal Family Medical Leave Act for up to twelve weeks of unpaid leave in a twelve month period. In addition to workers’ compensation, other leaves that family medical leave may run concurrently with, are sick leave, vacation leave, and short-term disability.

If you have any questions in regard to this, please feel free to contact me at the below listed number.

Sincerely,

MCCF10/22/2018

FMNOT

RE:Family/Medical Leave Request

Patient:

Employer:

Employee ID No.:

Date/ Absence(s):

Dear :

This letter is to inform you that we have received your request for Family Medical Leave and are currently in the process of making a determination. Your current leave of absence will be provisionally counted against your annual family medical leave entitlement. You will receive, under separate cover, our final determination of your request.

If you have any questions in regard to this, please feel free to contact me at the below listed number.

Sincerely,

MCCF10/22/2018

FMREQ

RE:Family and Medical Leave

Employee ID No:

Dear:

We received your Request for Family Medical Leave on , indicating your absence(s) on for Family and Medical Leave due to:

a serious health condition that makes you unable to perform the

essential functions of your job;

a serious health condition affecting your spouse, child,

parent for which you are needed to provide care;

This is to inform you that you are not eligible for leave under the FMLA. If it is determined at a later date that you are eligible for FMLA, the leave taken will be counted against your annual entitlement under the federal law the state law both federal and state law.

UNTIMELY FILING

The request form you completed was signed on , and you were absent from work, . The Family Medical Leave Act specifically states that, “Employees may have absences retroactively designated as Family Medical Leave only if the employee provide a minimum of 30-days notice for “foreseeable” leave (childbirth, foster care, adoption, planned medical care/surgery); otherwise provide notice “as is practicable” (emergency, unexpected event, birth, etc.) (ordinarily would mean at least verbal notification to the employer within one or two business days of when the need for leave becomes known to the employee.) and/or follow employer’s usual/customary reporting procedure.

DATE OF HIRE

It was indicated on your request form that your date of hire with was on . Federal law specifies that eligible employees have been, “Employed at least 12 months and worked 1,250 hours in the past 12 months.” Therefore, you are not eligible for any family medical leave until such time that you have met one of the specifications listed above. The state law specifies that eligible employees have, “1. Been employed at least 180 days; and 2. Worked an average of more than 25 hours per week.”

NON SERIOUS HEALTH CONDITION

The information you submitted for your family medical leave request did not support a finding that your condition qualifies as a serious health condition under federal or state requirements. Therefore your absence does not qualify, and will therefore not be counted against your federal or state family leave entitlement.

For other information regarding your rights under the FMLA, please feel free to contact me at the below address.

Sincerely,

MCCF10/22/2018

REREQ -

RE:Family/Medical Leave Request

Patient:

Employer:

Employee ID No.:

Date/ Absence(s):

Dear :

However, prior to making a final determination of your request, you will need to have your physician complete the enclosed Certification of Health Care Provider. Once the form is completed, it must be returned to me at the address below within 30 days of the date of this letter.

If you have any questions in regard to this, please feel free to contact me at the below listed number.

Sincerely,

MCCF10/22/2018

FAREQ

Certification of Health Care Provider

(Family and Medical Leave Act)

The purpose of this form is to determine whether the employee’s medical condition qualifies as a disability leave and/or Family and Medical

Leave (“FMLA”).

TO BE COMPLETED BY HEALTH CARE PROVIDER

1a.Employee’s name:1b. Social Security number:

2a.Patient’s name:2b. Relationship to employee:

Patients name (If other than employee):

3a.Date medical condition commenced:3b. Date of most recent treatment:

4.Expected date employee should be able to return to his or her job:

5.If it is medically necessary for the employee to be absent from work on an intermittent basis or to work less than the employee’s

normal schedule of hours per day or days per week, indicate a suggested schedule of treatments and the expected duration of such treatments.

6a.Does the employee or immediate family member have a serious health condition that meets one or more of the conditions listed as a. through g. on the back of this form? Which condition? None

6b.Please describe the medical facts, which support your certification, including a brief statement as to how the medical facts meet

the criteria of the category checked above.

7a.Signature of health care provider: 7b. Date:

8.Type of practice (filed of specialization, if any):

9.Health care provider’s address and telephone number:

TO BE COMPLETED BY EMPLOYEE REQUESTING DISABILITY LEAVE FOR HIS/HER OWN MEDICAL CONDITION

You are hereby authorized to release to Company Name, or any designated representative or surety thereof:

1) Any and all relevant information (including but not limited to my history and work restrictions) you may have relative to

my condition while under your observation and treatment, and 2) hospital records for examination and copying, including

photocopying. A photocopy of this authorization will be valid and should be accepted with the same effect as the original.

Employee signature: Date:

TO BE COMPLETED BY EMPLOYEE REQUESTING FMLA LEAVE TO CARE FOR AN IMMEDIATE FAMILY MEMBER

When family leave is needed to care for an immediate family member with a serious health condition, the employee shall state the

care or participation in care he or she will provide and an estimate of 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:

TO BE COMPLETED BY COMPANY REPRESENTATIVE

Designated as qualified FMLA leave  Yes  No

Supervisor Signature: Date:

A serious health condition is an illness, injury, impairment, physical or mental condition that involves:

a)Hospital Care: Inpatient care in a hospital, hospice, or residential care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.

b)ABSENCE / MULTIPLE TREATMENT: A period of incapacity of more than 3 calendar days that also involves treatment two or more times by a health care provider, a nurse, or physician’s assistant under direct supervision of a health care provider, or by a provider of health care services under orders of, or on referral by, a health care provider.

c)ABSENCE / TREATMENT REGIMEN: A period of incapacity of more than 3 calendar days that also involves treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.