EMPLOYEE REQUEST AND
EMPLOYER RESPONSE
FOR FAMILY OR MEDICAL LEAVE
(Family Medical Leave Act of 1993)
PART A: EMPLOYEE REQUEST
EMPLOYEE'S NAME: _____________________________________
MANAGER'S NAME: ______________________________________
I am notifying you of my need to take family/medical leave due
to:
_____________the birth of a child, or the placement of a child
for adoption or foster care; or
_____________a serious health condition that makes me unable to
perform the essential functions of my job; or
_____________a serious health condition affecting my ____ spouse,
____ child, ____ parent, for whom I need to provide care.
The Family and Medical Leave Act (FMLA) provides
for up to 12 weeks unpaid leave in a 12-month period for the
reasons listed above. 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 condition which would entitle you to
a FMLA leave: or (2) other circumstances beyond your control, you
may be required to reimburse the U.S. House of Representatives
for your share of health insurance premiums paid on your behalf
during your FMLA leave.
You may elect to substitute accrued leave for unpaid FMLA leave.
The employing authority may or may not require that you
substitute accrued paid leave for unpaid FMLA leave.
It is your responsibility to maintain your health benefits during
any period of unpaid leave under the same conditions as if you
continued to work. Since you normally pay a portion of the
premiums for your health insurance, these payments will continue
during the period of FMLA leave. Please make payment arrangements
with the Office of Personnel and Benefits.
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, unless noted otherwise in PART B. You may
or may not be designated as a "key employee" as
described in § 825.218 of the FMLA regulations. If you are a
"key employee," restoration to employment may be denied
following FMLA on the grounds that such restoration will cause
substantial and grievous economic injury to the employing
authority.
You may be required to provide a medical
certification or recertification of your condition. You may also
be required to provide a fitness for duty certification letter
from your health care provider affirming your ability to resume
work prior to returning to employment.
DATES OF FMLA LEAVE:
I am requesting FMLA leave without pay beginning on
___________________________ (date) ,
and expect to return to work on, or about,
____________________________________ (date).
DATES OF FMLA INTERMITTENT LEAVE:
I am requesting to use intermittent FMLA leave without pay on an
intermittent leave schedule, as provided by the Family Medical
Leave Act of 1993 (FMLA), beginning on
_____________________________________________ (date).
I am also aware that the total amount of FMLA leave to which I am
entitled (to include intermittent leave) may not surpass 12
workweeks of leave per year, (60 days/480 hours).
An example of an FMLA intermittent leave schedule would be:
"20 hours per week, not to exceed 50%, 1/2 pay per month,
through May 31, 1996.
I intend to return from leave on June 1, 1996."
My requested FMLA intermittent leave schedule is as follows:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
The use of FMLA leave on a intermittent or reduced leave schedule
in effect may equate to part-time employment, however the
employees official duty status does not change.
Employee Signature __________________________________
Date________________________________
PART B: EMPLOYER RESPONSE
This is to inform you that : (check appropriate boxes; explain
where indicated)
1. You are ____ eligible, ______not eligible, for leave under the
FMLA.
2. The requested leave _____ will, _____ will not, be counted
against your annual FMLA leave entitlement.
3. You will, will not, be required to furnish medical
certification of a serious health condition.
If required, you must furnish certification by
_____________(insert date)(must be at least 15 days after you are
notified of this requirement) or we may delay the commencement of
your leave until the certification is submitted.
4. You may elect to substitute accrued paid leave for unpaid
FMLA. We ______ will, ______ will not, require that you
substitute accrued paid leave for unpaid FMLA leave. If paid
leave will be used, the following conditions will apply:
(Explain)
5. You _____ will, ______ will not, be required to present a
fitness for duty certification letter -or- certification letter
affirming your ability to resume work before being restored to
employment. If such certification is required but not received,
your return to work may be delayed until certification is
provided.
6(a) You _____ are, _____ are not, a "key employee" as
described in § 825.218 of the FMLA regulations. If you are a
"key employee," restoration to employment may be denied
following FMLA on the grounds that such restoration will cause
substantial and grievous economic injury to us.
(b) We _____ have, ______ have not, determined that restoring you
to employment at the conclusion of FMLA leave will cause
substantial and grievous economic harm to the employing
authority. (Explain (a) and/or (b) below. See § 825.219 of
the FMLA regulations.)
7. While you are on leave, you ______ will, ______ will not, be
required to furnish us with periodic reports every _____
(indicate interval of periodic reports, as appropriate for the
particular leave situation) of your status and intent to return
to work (see § 825.309 of the FMLA regulations). If the
circumstances of your leave change and you are able to return to
work earlier than the date indicated on the reverse side of this
form, you _____ will, ______ will not be required to notify us at
least two work days prior to the date you intend to report for
work.
8. You _____ will, ______ will not be required to furnish
recertification relating to a serious health condition. (Explain
below, if necessary, including the interval between
certifications as prescribed in § 825.308 of the FMLA
regulations.)
Supervisor Signature ________________________________ Date
___________________________
Human Resource Official _________________________________ Date
________________________
PLEASE NOTE:
It is your responsibility to maintain your health benefits during
any period of unpaid leave under the same conditions as if you
continued to work. Since you normally pay a portion of the
premiums for your health insurance, these payments will continue
during the period of FMLA leave. Please make payment arrangements
with the Office of Personnel and Benefits.
OFFICE OF HUMAN RESOURCES
U.S. HOUSE OF REPRESENTATIVES
__________________________________________________
CERTIFICATION OF HEALTH CARE PROVIDER
(Family Medical Leave Act of 1993)
__________________________________________________
1) EMPLOYEE'S NAME: _____________________________________
2) PATIENT'S NAME: _______________________________________
(If different from employee)
3) The definition section (which follows) describes what is meant
by a "serious health condition" under the Family and
Medical Leave Act. Does the patient's condition qualify under any
of the categories described? If so, please check the applicable
category.
(1)_____ (2)_____ (3)_____ (4)_____ (5)_____ (6)_____ , or, none
of the above______ .
4) Briefly describe the medical facts which support your
certification, including a brief statement as to how the medical
facts meet the criteria of one of the above categories:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
5) A) State the approximate date the condition commenced, and the
probable duration of the condition, and the probable duration of
the patient's present incapacity (if different):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
B) Will it be necessary for the employee to work intermittently
or to work on a less than full schedule as a result of the
condition (including for treatment described in Item 6)?
YES _____ NO _____ If YES, give the probable duration of the
intermittent work schedule:
C) If the condition is a chronic condition (condition #4) or
pregnancy, state whether the patient is presently incapacitated
and the likely duration and frequency of episodes of incapacity:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
6) A) If additional treatments will be required for the
condition, provide an estimate of the probable number of such
treatments:
_________________________________________________________________________________________
_________________________________________________________________________________________
If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any: ______________________________________________________________________________
__________________________________________________________________________________________
B) If any of these treatments will be provided by another
provider or health service (e.g., physical therapist), please
state the nature of the treatments:
__________________________________________________________________________________
___________________________________________________________________________________________
C) If a regimen of continuing treatment by the patient is
required under your supervision, provide a general description of
such regimen (e.g., prescription drugs, physical therapy
requiring special equipment, etc.):
_______________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
7) A) If medical leave is required for the employee's absence
from work because of the employee's own condition (including
absences due to pregnancy or a chronic condition), is the
employee unable to perform work of any kind?
YES ______NO ________
B) If able to perform some work, is the employee unable to
perform any one or more of the essential functions of the
employee's job (the employee or the employer should supply you
with information about the essential functions of the employee's
job)?
YES _______ NO _________ If YES, list the essential functions the
employee is unable to perform:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
C) If neither (A) nor (B) applies, is it
necessary for the employee to be absent from work for treatment?
YES ______ NO _______
8) A) If leave is required to care for a family member of the
employee with a serious health condition, does the patient
require assistance for basic medical or personal needs or safety,
or for transportation?
YES ______ NO ______
B) If NO, would the employee's presence to provide psychological
comfort be beneficial to the patient or assist in the patient's
recovery?
YES _____ NO ______
C) If the patient will need care only intermittently or on a
part-time basis, please indicate the probable duration of this
need:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________
___________________________________
(Signature of Health Care Provider) --------------------(Type of
Practice)
__________________________________
___________________________________
(Address)
----------------------------------------------(Telephone Number)
The following is to be completed by the employee only if
family leave is needed to care for a family member:
State the care you will provide and an estimate of the period
during which care will be provided, including a schedule if leave
is to be taken intermittently or if it will be necessary for you
to work less than a full schedule:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________
___________________________________
(Employee Signature)
------------------------------------------(Date)
DEFINITIONS:
A "Serious Health Condition" means an illness, injury,
impairment, or physical or mental condition that involves one of
the following:
1) HOSPITAL CARE
Inpatient care (i.e., an 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) A period of incapacity of more than three consecutive calendar
days (including any subsequent treatment or period of incapacity
relating to the same condition), that also involves:
1) Treatment two or more times by a health care provider, by a
nurse or physician's assistant under direct supervision of a
health care provider, or by a provider of health care services
(e.g., physical therapist) under orders of, or on referral by, a
health care provider; or
2) 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.
3) PREGNANCY
Any period of incapacity due to pregnancy, or
for prenatal care.
4) CHRONIC CONDITIONS REQUIRING TREATMENTS
A chronic condition which:
1) Requires periodic visits for treatment by a
health care provider, or by a nurse or physician's assistant
under direct supervision of a health care provider;
2) Continues over an extended period of time
(including recurring episodes of a single underlying condition);
and
3) May cause episodic rather than a continuing
period of incapacity(3) (e.g., asthma, diabetes, epilepsy, etc.)
5) PERMANENT/LONG-TERM CONDITIONS REQUIRING SUPERVISION
A period of incapacity (3) which is permanent or
long-term due to a condition for which treatment many
not be effective. The employee or family member must be under
the continuing supervision of, but need not be receiving active
treatment by, a health care provider. Examples include
Alzheimer's, a severe stroke, or the terminal stages 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 health care
provider or by a provider of health care services under orders
of, or on referral by, a health care provider, either for 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).