REQUEST FOR FAMILYMEDICAL LEAVE (Feb 2013)

The following terms and conditions are applicable to your requested FMLA leave of absence, if granted.

  • You must have been employed at least 12 months and worked at least 1,250 hours in the past 12 months.
  • Leave taken will be counted against the annual FMLA entitlement.
  • Failure to provide a medical certification, if requested, will result in a denial of FMLA leave.
  • The leave shall generally be unpaid. However, certain kinds of paid leave may be substituted for unpaid leave.
  • FMLA leave is calculated on a “rolling” twelve month period backward from the first day the FMLA leave is used.
  • You must have a medical certification form completed by the attending health care provided to support a request for leave to care for yourself or a family member. A recertification during the leave will also be required.
  • A fitness for duty report is required from the attending health care provider returning from leave after a serious health condition.
  • During FMLA leave, your coverage under the group health plan will continue. However, you must continue to pay your dependent insurance premiums (if applicable). Failure to make timely premium payments may cause your coverage to lapse. In addition, you must reimburse the College for any premium payments made on your behalf while you are on FMLA leave.
  • The College will cease making premium payments for group insurance benefits other than health insurance when an employee goes off the payroll.
  • Upon return from FMLA leave, most employees will be restored to their same or equivalent position with equivalent pay, benefits and other employment terms.
  • Failure to return to work upon expiration of FMLA leave may result in termination.
  • If you do not return to work or contact your supervisor or manager on the date of your scheduled return, you will be considered to have abandoned your job.
  • While on leave, you must contact the Human Resource Office every Friday with an update.

PLEASE PRINT

NAME: ______DATE: ______

ADDRESS______HIRE DATE: ______

______

FULL TIME_____PART TIME______Monthly______BiWeekly______

I request family or medical leave for one or more of the following reasons.

____For a serious health condition which makes me unable to perform the functions of my job. (12 weeks)

____To care for mychild after birth, or placement for adoption or foster care (12 weeks).

____To care for my spouse, son or daughter, or parent who has a serious health condition. (12 weeks)

____For my spouse, child or parent who is on active duty or has been notified of an impending call or order to active duty in the Armed Forces in support of a contingency operation (Qualifying Exigency Leave) (12 weeks)

____To care forserious illness or injury of covered Servicemember (Servicemember Family Care Leave) (26 weeks)
____To care for serious illness or injury of covered veteran.

Expected Date of Surgery, Medical Treatment, Birth or Adoption:______

Leave to Start: ______Expected Date of Return:______

____Request intermittent or reduced hours leave schedule if applicable and subject to College approval.
If you check this, you MUST submit any and all hours you work each week in writing to the Human Resource Office. Failure to comply will result in charging you for full-day (8 hours) of FMLA Leave.

EMPLOYEE BENEFITS

You may continue to participate in certain employee benefit plans during your leave of absence. Each plan available to you, the length of time you may continue participation, and required premium contributions are as follows (check the plans you wish to continue during your leave period). If you fail to return to work after the leave, you will be financially responsible for the total cost (employer and employee portions) of any and all employee benefits maintained during FMLA leave.

If you fail to make timely required premium contributions may cause your coverage to lapse. Reinstatement to each plan will be made in accordance with the terms of each plan, subject to the requirements of the FMLA.

______

EMPLOYEE SIGNATUREDATE

LEAVE APPROVAL

_____Approved____Disapproved Attach explanation if leave is denied. Attach documentation of any dispute or disagreement over granting or denying FMLA leave.

______

Human Resource Staff MemberDate