223644384730457 Theme:63b84eb33136370a9e6bbb40

Name

First NameLast Name

Employer Name

Job Title

List of Employee's essential job functions:

CONTACT INFORMATION

Phone Number:

Please enter a valid phone number.

Mailing Address:

Email Address:

Select your preferred method of contact:

PhoneMailing AddressEmailUpdate my contact information

Below is a description of various “serious health conditions” categories that usually qualify under the Family & Medical Leave Acts. Please check the category(s) that apply to your situation:

Please Check

DEFINITION OF A “SERIOUS HEALTH CONDITION”

A "serious health condition" is defined as an illness, impairment, physical or mental condition that involves one of the following:

1. Hospital care

Inpatient care (i.e., overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.

2. Absence plus treatment

A period of incapacity of more than three consecutive calendar days (including any period of incapacity or subsequent treatment relating to the same condition), that also involves:

a. Treatments two or more times, within 30 days of the first day of incapacity, unless extenuating circumstances exist, by a licensed healthcare provider, nurse, or physician's assistant under direct supervision of a healthcare provider, or by a provider of healthcare services (e.g., physical therapist) under orders of, or on referral by, a healthcare provider and with the first (or only) in-person treatment visit taking place within seven days of the first day of incapacity, or;

b. Treatment by a healthcare provider on at least one occasion which results in a regimen of continuing treatment under supervision of the healthcare provider.

1. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment DOES NOT include routine physical, dental, or eye examinations.

2. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment DOES NOT include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, or any other similar activities that can be initiated without a visit to a healthcare provider.

3. Pregnancy/Prenatal care

Any period of incapacity due to pregnancy, pregnancy-related illness, or for prenatal care.

4. Chronic conditions requiring treatments

A chronic serious health condition is one which:

a. Requires periodic visits (defined as at least twice a year) for treatment by a healthcare provider, nurse, or physician's assistant under direct supervision of a healthcare provider;

b. Continues over an extended period of time (including recurring episodes of a single underlying condition); and

c. (c) May cause episodic rather than continuing periods of incapacity (e.g., asthma, diabetes, epilepsy, etc.)

5. Permanent/ long-term condition requiring

A period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a healthcare provider. Examples include Alzheimer's, a severe stroke or the terminal states of a disease.

6. Multiple treatments (non-chronic conditions)

Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a healthcare provider or by a provider of healthcare services under orders of, or on referral by, a healthcare provider, either of restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Definition of Incapacitated

Inability to work, attend school, or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom.

Definition of Treatment:

Includes examinations to determine if a serious health condition exists and for evaluations of the condition. The definition does not include routine physical examinations, eye examinations or dental examinations.

Whats your Health condition

Briefly describe your serious health condition:

HealthCare Provider Name

First NameLast Name

HealthCare Provider Office Name

HealthCare Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Practice/Health Specialty

Telephone

Please enter a valid phone number.

Fax

Email

example@example.com

Proposed Leave Schedule

A Single Block of Time (as supported by a health care certificate).Reduced Work ScheduleIntermittent Leave (As Supported By A Health Care Certificate) -when The Need ArisesReasonable Accommodation(s)Transfer/assignment To A Less Strenuous Or Hazardous Position Or Dutie (You Can Request Or The Company May Require You To Accept A Temporary Transfer To A Different Position):

A SINGLE BLOCK OF TIME

Beginning (Estimate):

Date

Ending (Estimate):

Date

Reasonable Accommodation(s)

Beginning (Estimate):

Date

Ending (Estimate):

Date

REDUCED WORK SCHEDULE

I proposed to work blanks hour(s) per day Ty. per week (and supported by a health care certificate) as follows: Type a label

Beginning (Estimate):

Date

Ending (Estimate):

Date

INTERMITTENT LEAVE

Estimate the intermittent leave schedule:

Beginning (Estimate):

Date

Ending (Estimate):

Date

Proposed Accommodation

Proposed Transfer

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164)

1.I blanks, (the patient or representative) hereby authorize and request the Health Care Provider noted below (and its agents) to release my protected health information (PHI) to :ABC Company for purposes of certifying my serious health condition under Federal and state FMLA and other leave laws

2. Authorization for release of PHI related to my serious health condition for the period of health care (check as appropriate)

from (date)_____to (date)_____ ORall past, present and future periods; ORall records relating to:_____ from (date)_____- to (date)

form (date)Date to (date)Date OR

all records relating to:Date form (date)Date - to (date)

3. I hereby authorize the release of PHI as follows:

records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse) related to the serious health condition. ORmy health record related to the serious health condition with the exception of the following (check as appropriate):Mental health recordsAlcohol/drug abuse treatmentCommunicable diseases (including HIV and AIDS)Other

4. I authorize the medical information to be used by ABC Company personnel (and its agents) responsible for determining eligibility for federal and state FMLA and other leave laws or responsible for the audit or facilitation the evaluation or effectiveness of the Company’s leave laws (such as IT personnel).

I authorize

5. I understand that I am entitled to a copy of ABC COMPANY’s Notice of Privacy Practices. I can access a copy of the Notice of Privacy Practices from the website abccompany.com/privacypractices.html or from ABC Company's office directly.

I understand

Your PHI will be release to:

Name: Brittany Walters
Employer: Nathson & Associates, FMLA/Leave Administrstor
Address; 145 Imperial Dr
Shaker Heights, Ohio 44120
Phone: 216-547-2612
E-mail: bwalters@nathson.com

FMLA/SPF Coordinator

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone Number

Please enter a valid phone number.

Fax Number

Email

example@example.com

Certification and Acknowledgement: I certify that I am the person (or the personal representative of the person) designated in Part 1. I agree that my individually identifiable health information described in Parts 3 and 4, and held by the person or entity listed in Part 2, may be disclosed to the person or entity listed in Part 5 for the purpose(s) designated in Part 6. I understand that, if the information to be disclosed is needed by a health care plan in order to determine my eligibility for plan benefits; or is needed by ABC Company to consider me for medical, sick or other leave; or to consider my eligibility or claim for short- or long-term disability or life insurance coverage or benefits, workers’ compensation benefits, or similar fringe benefits; or to consider me for employment or continued employment, my failure to provide this Authorization may prevent me from receiving the benefit or leave, or preclude me from being considered for employment or continued employment. I understand that I have the right to revoke this Authorization, in writing, at any time, by sending the revocation to the person or entity who received the Authorization, and that the revocation will be effective except to the extent that the person or entity releasing the information has already taken action in reliance on my Authorization. I understand that, once disclosed, it is possible that the health information may be further disclosed by the recipient and no longer subject to protection under international, federal, state, or local privacy rules. I have received a copy of my signed Authorization.

Date

Name

First NameLast Name

If this authorization is signed by a personal representative of the above-named patient, the personal representative must describe his or her authority to act:

Exception(s)

Signature of Witness

Date

Signature of Witness

Date

Witnesses only need if ABC Company requests witnesses as required by law

This form is to be completed by the patient’s health care provider. FMLACERT@nathson.com

Information sought on this form relates only to the condition for which the employee is taking leave.

Date Prepared:

Date

Must Be Returned By:

Employee Name

Employer Name

Patient's Name (if different from employee):

Employee Job Title:

Regular Work Schedule:

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA/OFLA, Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA/OFLA coverage. Limit your responses to the condition for which the employee is seeking leave.

EMPLOYEE LEAVE REQUEST:

The type and amount of leave the employee has requested:

A SINGLE BLOCK OF TIME (for example, three weeks of leave for surgery and recovery ((and supported by a health care certificate).REDUCED WORK SCHEDULEINTERMITTENT LEAVE (and supported by a health care certificate) -WHEN THE NEED ARISES

A SINGLE BLOCK OF TIME

Beginning (Estimate):

Date

Ending (Estimate):

Date

REDUCED WORK SCHEDULE

I proposed to work blanks hour(s) per day Ty. per week (and supported by a health care certificate) as follows:

Beginning (Estimate):

Date

Ending (Estimate):

Date

INTERMITTENT LEAVE

Estimate the intermittent leave schedule:

Beginning (Estimate):

Date

Ending (Estimate):

Date

Information sought on this form relates only to the condition for which the employee is taking leave.

Employee's Name:

On the reverse of this sheet is a description of various "serious health condition" categories that qualify under the Family and Medical Leave Acts. Please check appropriate category or categories:

1-Hospital care2-Absence plus treatment3-Pregnancy and/or prenatal care4-Chronic condition requiring treatment5-Perm/long-term condition requiring supervision6-Multiple treatments (non-chronic condition)

Provide a description of the medical facts that support your certification and explain how they meet the criteria of the category:

Approximate date condition began and probable duration: from through

Probable duration of patient’s present incapacity (if different): from through

If this is a chronic condition or pregnancy, is the patient presently incapacitated (see reverse side for definition)?

YesNo

If yes, duration and frequency of episodes of incapacity:

Will it be necessary for the employee to take leave only intermittently or to work on a less than full-time schedule basis because of the condition or treatment?

YesNo

If yes, duration:

Frequency:

One to two days per month Two to three days per monthThree to four days per monthOther:Please explain how the employee will use leave

intermittently or work a less than full-time schedule. Be as specific as possible including frequency and duration of absences:

If the patient requires a regimen of treatment, what is the nature of and description of the treatments, estimated number of treatments, and intervals between treatments (see reverse side for definition)? (Note: If the employee is requesting leave under the California Family Rights Act or the Connecticut Family and Medical Leave Act, do not include diagnosis information):

What are the actual or estimated dates of visits for treatment, or frequency of visits for treatment?

What is the duration of each treatment and any period required for recovery?

If this certification relates to the employee's seriously ill family member(s), also complete the following :

Does the patient require assistance for basic medical or personal needs, safety, or for transportation?

YesNo

If no, would the employee’s presence to provide psychological comfort be beneficial or assist in the patient’s recovery?

YesNo

If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration and frequency of this need:

Employee’s essential job functions:

Check if job description is attached:

Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions?

YesNo

If yes, explain

Is the employee unable to perform any of his/her job functions due to the condition based on the employee’s own description of his/her job?

YesNo

If yes, identify the job functions the employee is unable to perform:

Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment) (Note: If the employee is requesting leave under the California Family Rights Act or the Connecticut Family and Medical Leave Act, do not include diagnosis information):

Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? No Yes

YesNo

If “yes”, estimate the beginning and end dates for any period of incapacity:

If this certification relates to the employee’s seriously ill family member(s), also complete the following:

Does the patient require assistance for basic medical or personal needs or safety, or for transportation?

YesNo

Would the employee’s presence to provide psychological comfort be beneficial or assist in the patient’s recovery?

YesNo

If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration and frequency of this need:

Please explain the care needed by the patient:

Affirmative answer to the following question is not required for OFLA or concurrent OFLA/FMLA leave.

Is this care medically necessary?

YesNo

Will the patient require follow-up treatments, including any time for recovery?

YesNo

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

Affirmative answer to the following question is not required for OFLA or concurrent OFLA/FMLA leave.

Is this care medically necessary?

YesNo

Printed Name of Physician/ Practitioner

Date Signed

Date

Signature of Physician/ Practitioner

Type of Practice/ Field of Specialization

Address

Phone Number

Please enter a valid phone number.

Definition of a "Serious Health Condition":

A "serious health condition" is defined as an illness, impairment, physical or mental condition that involves one of the following:

Hospital care –Inpatient care (i.e., overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.

Absence plus treatment –A

period of incapacity of more than three consecutive calendar days (including any period of incapacity or subsequent treatment relating to the same condition), that also involves:

a. Treatments two or more times by a licensed healthcare provider, nurse, or physician's assistant under direct supervision of a healthcare provider, or by a provider of healthcare services (e.g., physical therapist) under orders of, or on referral by, a healthcare provider, or

b. Treatment by a healthcare provider on at least one occasion which results in a regimen of continuing treatment under supervision of the healthcare provider.

1. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment DOES NOT include routine physical, dental, or eye examinations.

2. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment DOES NOT include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, or any other similar activities that can be initiated without a visit to a healthcare provider.

Pregnancy –

Any period of incapacity due to pregnancy, pregnancy-related illness, or for prenatal care.

Chronic conditions requiring treatments –

A chronic serious health condition is one which:

a. Requires periodic visits for treatment by a healthcare provider, nurse, or physician's assistant under direct supervision of a healthcare provider;

b. Continues over an extended period of time (including recurring episodes of a single underlying condition); and

c. May cause episodic rather than continuing periods of incapacity (e.g., asthma, diabetes, epilepsy, etc.)

5. Permanent/ long-term conditions requiring supervision –

A period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a healthcare provider. Examples include Alzheimer's, a severe stroke or the terminal states of a disease.

6. Multiple treatments (non-chronic conditions) –

Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a healthcare provider or by a provider of healthcare services under orders of, or on referral by, a healthcare provider, either of restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Definition of "Incapacitated": Inability to work, attend school, or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom.

Directions regarding “Regimen of treatment" (question 7): If the patient is under your supervision, provide a general description of such regimen, such as prescription drugs or physical therapy requiring special equipment. If the treatments will be provided by another provider of health services, such as a physical therapist, please state the nature of the treatments.

Upload certificate

ToDate EE# Type a label . To Date From Date

Eligibility does not mean approval. Once we obtain the information from what you specified in Section II, we will inform you whether your leave will be designated as Family and Medical Leave Act (FMLA)/California Family Rights Act (CFRA) leave and count toward your leave entitlement. In general, to be eligible an employee must have worked for the County for at least 12- months, and meet the hours of service requirement in the 12-months preceding the leave. Section III provides employees with information regarding their rights and responsibilities for taking FMLA only, CFRA only or FMLA/CFRA leave.

On this date you informed us that you needed Date leave beginning on Date

Reason for the leave request

The birth of a child, or placement of a child with you for adoption or foster care.Your own serious health condition, including a workers’ compensation injury.Your own pregnancy, childbirth or related medical condition. You’re needed to care for your family member due to a serious health condition.A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of an impending call or order to covered active duty status.You are needed to care for your family member who is a covered servicemember with a serious injury or illness.

This Notice is to inform you that you:

Are eligible for: FMLA leave,CFRA leave,FMLA/CFRA running concurrentlyAre not eligible for FMLA or CFRA leaveYou have not met the FMLA/CFRA’s 12-month length of service requirement. As of the first date of requested leave, you will have worked approximatelyYou have not met the FMLA/CFRA’s 1,250 hours of service requirement. As of the first date of requested leave, you’ll have worked approximatelyYou have exhausted your FMLA entitlement.You do not work and/or report to a site with 50 or more employees within 75 miles

If you have any questions, contact your TWIRL representation Barend Walters on the Leave Plan Portal or view the FMLA poster on the Portal.

FMLA/CFRA-Notice of Eligibility and Rights and Responsibililities

As explained in Section I, you meet the eligibility requirements for taking FMLA and/or CFRA leave. Please review the information below to determine if additional information is needed in order for us to determine whether your absence qualifies as FMLA/CFRA leave. Once we obtain any additional information specified below we will inform you, within 5 business days, whether your leave will be designated as FMLA/CFRA leave and count towards the FMLA/CFRA leave you have available. If complete and sufficient information isn’t provided in a timely manner, your leave may be denied.

No additional information requested. If no additional information is requested, go to Section III.

We request that the leave be supported by a certification as identified below.

Health Care Provider for the employeeHealth Care Provider for the Employee’s Family MemberQualifying ExigencySerious Illness or Injury (Military Caregiver Leave)

Selected certification form is attached

If requested, medical certification must be returned by

(Must allow no less than 15 calendar days from receipt of this notice; additional time may be required in some circumstances.)

We request that you provide reasonable documentation or a statement to establish the relationship between you and your family member, including loco parentis relationship. The information must be returned to us By:

Date

Information requested must be returned by:

Date

You have a right under the CFRA for up to 12 weeks and under FMLA for up to (check one):

12 weeks18 weeks

You have a right under the CFRA for up to 12 weeks and under FMLA for up to (check one):

12 weeks18 weeks

Under FMLA only, you have the right to take unpaid job protected leave up to (check one)

12 weeks18 weeks

If applicable, the single 12-month period for Military Caregiver Leave started on

Date

You have a right under the FMLA/CFRA to request that your accrued paid leave be substituted for your FMLA/CFRA leave provided you meet any applicable requirement of the Company leave policy. Concurrent leave use means the absence will count against both the designated paid leave and unpaid FMLA/CFRA leave at the same time. If you do not meet the requirements for taking paid leave, you remain entitled to take available unpaid FMLA.CFRA leave in the applicable 12 month period. Even if you do not request it, the FMLA/CFRA allows the Company to require you to use your available sick, vacation, orother paid leave during your FMLA/CFRA absence.

Some or all of your FMLA/CFRA leave will not be paid. Any unpaid FMLA/CFRA leave taken will be designated as FMLA/CFRA leave and counted against the amount of FMLA/CFRA leave you have available to use in the applicable 12-month period.You have requested to use some or all of your available paid leave (e.g., sick, vacation, other leaves) during your FMLA/CFRA leave. Any paid leave taken for this reason will also be designated as FMLA/CFRA leave and counted against the amount of FMLA/CFRA leave you have available to use in the applicable 12-month period.

FMLA/CFRA-Notice of Eligibility and Rights and Responsibililities

We are requiring you to use some or all of your available paid leave (e.g., sick, vacation, other leaves) during your FMLA/CFRA leave. Any paid leave taken for this reason will also be designated as FMLA/CFRA leave and counted against the amount of FMLA/CFRA leave you have available to use in the applicable 12-month period.Other: (e.g., short- or long-term disability, workers’ compensation, etc.)

Any time taken for this reason will also be designated as FMLA/CFRA leave and counted against the amount of FMLA/CFRA leave you have available to use in the applicable 12-month period.

Applicable conditions for use of paid leave:

For a copy of conditions applicable to sick/ vacation/ other leave usage, please refer to:

available at:

Date

Part C: Maintain Health Benefits

Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work. During any paid portion of FMLA/CFRA leave, your share of any premiums will be paid by the method normally used during any paid leave. During any unpaid portion of FMLA/CFRA leave, you must continue to make any normal contributions to the cost of the health insurance premiums. To make arrangements to continue to make your share of the premium payments on your health insurance while you are on any unpaid FMLA/CFRA leave, contact the Employee Benefits Department at (925) 655-2100. You have a minimum 30-day grace period in which to make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse.

You may be required to reimburse the Company for their share of health insurance premiums paid on your behalf during your FMLA/CFRA leave if you do not return to work following unpaid FMLA/CFRA leave for a reason other than: the continuation,recurrence, or onset of your or your family member’s serious health condition which would entitle you to FMLA/CFRA leave;or the continuation, recurrence, or onset of a covered servicemember’s serious injury or illness which would entitle you to FMLA leave; or other circumstances beyond your control.

Part D: Other Employee Benefits

Upon your return from FMLA/CFRA leave, your other employee benefits, such as pensions, deferred compensation, or life insurance, must be resumed in the same manner and at the same levels as provided when your FMLA/CFRA leave began. To make arrangement to continue your employee benefits while you are on FMLA/CFRA leave contact:Employee Benefits Department at (925) 655-2100 and CCERA (for pension only) at (925) 521-3960

Part E: Return-to-Work Requirements

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 FMLA/CFRA protected leave. An equivalent position is one that is virtually identical to your former position in terms of pay, benefits, and working conditions. At the end of your FMLA/CFRA leave, all benefits must also be resumed in the same manner and at the same level provided when the leave began. You do not have return-to-work rights under the FMLA/CFRA if you need leave beyond the amount of FMLA/CFRA leave you have available to use.

Misuse or abuse of approved FMLA/CFRA time is grounds for disciplinary action, up to and including termination.

If the circumstances of your leave changes and you are able to return to work earlier than the date indicated, you will be required to notify us at least two workdays priorto the date you intend to report for work.

Case/Record/Other ID Number and Identify Type name Email Email

Will you apply for Short Term Disability (STD)?

YesNoN/A

Will you apply for Short Term Disability (STD)?

YesNoN/A

Will you use salary continuation?

YesNoN/A

Will you use leave during any STD waiting period?

YesNoN/A

Specify the types of leave you wish to use, the dates on which to apply it, and the total for each

Sick LeaveVacationCompensatory TimeLeave without Paye

Use my special day on:

Use my personal days on:

I will use paid holidays on:

I wish to retain

hours of vacation (classified only, 40 hours maximum)

FAMILY AND MEDICAL LEAVE GUIDELINES

I understand that to be eligible for leave under the Family and Medical Leave Act, I must have been employed with the ABC Company for a cumulative total of 12 months AND have physically worked a minimum of 1,250 hours during the 12 months immediately preceding the beginning of the requested leave. If I do not meet eligibility, I understand that my request under FMLA will be denied. If my request for FMLA leave is approved, I understand that this period of leave will count toward the number of workweeks that I am entitled to under the Act. I understand that the 12 month period is a rolling 12 month period measured backward from the first date I use any FMLA leave. I also understand that under the rolling 12 month period, each time I take FMLA leave, the remaining entitlement is the balance of my unused workweeks. I understand that FMLA requests must be renewed or extended if the request and approved FMLA period has elapsed.

PARENTAL LEAVE GUIDELINES

I understand that under the provisions of Parental Leave from Company policy, I can take up to six months unpaid leave when I become the biological or adoptive parent of a child. I understand that Parental Leave may not begin more than two weeks prior to the expected date of the child’s arrival without supervisor and HR approval. I understand that Parental Leave may run concurrent with Family and Medical Leave entitlements. I understand that while on parental leave, I may request and be placed on annual leave with pay to cover any part of the six months period until all or any part of my earned annual leave has been used. I also understand that by completing the required medical certification, I may be allowed to use earned sick leave while on parental leave.

CERTIFICATION

I understand that the Family and Medical Leave/Parental Leave Health Care Certification or the Injured Service Member Health Care Provider Certification form is required at the time of my request for leave due to the serious health conditions of me or my child, spouse, or parent. In the case of placement of a child through adoption or foster care, I understand that appropriate documentation from the agency or jurisdiction placing the child is required. In order to take service-member family leave, I understand documentation from the appropriate branch of the Armed Forces is required referencing need for support of the contingency operation.

I, acknowledge that my FMLA request is not valid until it has been certified and approved by Human Resources. I also understand the requirement to communicate with my supervisor and Human Resources on an ongoing basis, if there are any changes in my leave request or return to work date.

PERIODIC COMMUNICATION
The employee will be required to contact their supervisor every day(s) of the status and intent to return to work. (Employees are required to follow all call in procedures for all absences.)

	Employee INFORMATION
Name
Win
Date
City/State:
Expected Return to Work Date:

	Details
Cell/Text#:
Email:
ResponsivenessJob Title:
Date:

	Details
Employee:
ID#:
Positon/Job

Employee Information

Serious Health Condition

Who Is Your Health Care Provider?

Proposed Leave Schedule

HIPAA Privacy Authorization Form

Release my PHI to:

Attestation: I understand the nature of this authorization.

HEALTH CARE CERTIFICATION FORM

PART A: MEDICAL FACTS

PART B: AMOUNT OF CARE NEEDED

Initial Determination of Eligibility

FMLA/CFRA-Notice of Eligibility and Rights and Responsibilities

[SECTION I– NOTICE OF ELIGIBILITY]

[SECTION II - ADDITIONAL INFORMATION NEEDED]

[SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES]

Pay and Benefits During Leave

Employee Certification

Supervisor

HR summary

LEAVE ELIGIBILITY

LEAVE INFORMATION

COMPENSATION DURING LEAVE

BENEFIT ELECTIONS THE EMPLOYEE MAY CONTINUE DURING LEAVE.

Final Determination of Eligibility

FMLA/CFRA-Notice of Eligibility and Rights and Responsibilities

[SECTION I– NOTICE OF ELIGIBILITY]

[SECTION II - ADDITIONAL INFORMATION NEEDED]

[SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES]

Return to Work Certification

SECTION C – MANAGER/SUPERVISOR OR HR REPRESENTATIVE REVIEW

	Describe
If there are other job restrictions you have not described elsewhere, please describe here:
Is the employee currently prescribed medication that would impair job function or safety? If so, please describe:

Employee Information

Serious Health Condition

Who Is Your Health Care Provider?

Proposed Leave Schedule

HIPAA Privacy Authorization Form

Release my PHI to:

Attestation: I understand the nature of this authorization.

HEALTH CARE CERTIFICATION FORM

PART A: MEDICAL FACTS

PART B: AMOUNT OF CARE NEEDED

Initial Determination of Eligibility

FMLA/CFRA-Notice of Eligibility and Rights and Responsibilities

​[SECTION I– NOTICE OF ELIGIBILITY​]

​[SECTION II - ADDITIONAL INFORMATION NEEDED​]

​[SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES​]

Pay and Benefits During Leave

Employee Certification

Supervisor

HR summary

LEAVE ELIGIBILITY

LEAVE INFORMATION

COMPENSATION DURING LEAVE

BENEFIT ELECTIONS THE EMPLOYEE MAY CONTINUE DURING LEAVE.

Final Determination of Eligibility

FMLA/CFRA-Notice of Eligibility and Rights and Responsibilities

​[SECTION I– NOTICE OF ELIGIBILITY​]

​[SECTION II - ADDITIONAL INFORMATION NEEDED​]

​[SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES​]

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SECTION C – MANAGER/SUPERVISOR OR HR REPRESENTATIVE REVIEW

[SECTION I– NOTICE OF ELIGIBILITY]

[SECTION II - ADDITIONAL INFORMATION NEEDED]

[SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES]

[SECTION I– NOTICE OF ELIGIBILITY]

[SECTION II - ADDITIONAL INFORMATION NEEDED]

[SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIES]