Date: ________________________________
TO: ________________________________________________________________________________
FROM: ________________________________________________________________________________
SUBJECT: Request for Family & Medical Leave (FMLA Leave)
On ________________, you notified us of your need to take FMLA leave because of:
(date)
the birth of a child, or the placement of a child with you for adoption or foster care;
a serious health condition that makes you unable to perform the essential functions of your job;
or
a serious health condition affecting your
spouse
domestic partner
minor child
adult child incapable of self-care
parent.
You indicated that you need this leave to begin on ______________ and that you expect it to continue until ______________.
(date)
(date)
Except as explained below:
• you have a right under the FMLA to use up to 12 weeks of any combination of paid or unpaid leave in a leave year for the reasons listed above;
• your health benefits must be maintained during any period of unpaid FMLA leave under the same conditions as if you had continued to work; and
• 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.
If you do not return to work following FMLA leave, you must reimburse the County for the County share of health insurance premiums paid on your behalf during your FMLA leave, unless the reason for your failure to return is:
• the continuation, reoccurrence, or onset of a serious health condition which would entitle you to FMLA leave; or
• other circumstances beyond your control
Response to Employee Request for FMLA Leave
Page 2
NOTE: This form is available as a printer-friendly, PDF.
This is to further inform you that:
1. You are eligible not eligible for FMLA leave.
2. The leave you requested will will not be counted against your FMLA leave entitlement.
3. You will will not be required to furnish medical certification of a serious health condition to support your request for FMLA leave. If required, you must furnish certification by _______________________. (This date must be at least 15 days after you are notified of the requirement for medical certification.) If you do not submit the required certification, the approval of your leave may be delayed until it is received.
4. Unless you elect not to maintain your health insurance coverage during a period of unpaid FMLA leave or make other arrangements to pay your share of your health benefit premium during any period of unpaid FMLA leave, the County will continue to pay the entire premium until your return to a pay status. After your return, the County will recover the cost of your share of the premiums.
5. If you are absent from work for 15 or more consecutive workdays for your own serious health condition, you will be required to present a return-to-work authorization from your physician upon your return.
6. While on leave, you will will not be required to furnish periodic reports of your status and intent to return to work. If the circumstances of your leave change and you are able to return to work earlier than the date indicated in this letter, you will will not be required to notify us prior to your return to work.
7. You will will not be required to furnish us with re-certification (additional medical certifications) relating to your serious health condition or that of your immediate family member. Re-certification cannot be required any more frequently than every 30 days, unless there is a significant change in the circumstances that justified the original approval of FMLA leave.
8. I have attached:
further information about FMLA
a definition of serious health condition
a medical certification form
Attachments
Office of Human Resources