Fill and Sign the Fact Sheet 28 the Family and Medical Leave Actus Form

Family and Medical Leaves of Absence Provisions for Personnel or Employee Manual or Handbook _________________________ will grant a leave of absence to regular full-time and regular part-time employees (who meet the requirements described below) for the care of a child after birth or adoption or placement with the employee for foster care, the care of a family member (spouse, child, or parent) with a serious health condition, or in the event of an employee's own serious health condition. Leaves will be granted for a period of up to twelve weeks in any twelve-month period. An employee must have completed at least one full year of service with _________________________ and have worked a minimum of 1,250 hours in the twelve-month period preceding the leave to be eligible for such leave. In addition, to be eligi ble for leave, an employee must work at an _________________________ facility that employs at least fifty employees at that facility or within seventy-five miles of that facility. Child/Family Care Leave If you request a leave of absence to care for a child after birth, adoption, or placement in your home for foster care or to care for a covered family member with a serious health c ondition, you will be granted unpaid leave under the following conditions: 1. If the leave is planned in advance, you must provide us with at least thirty days' notice prior to the anticipated leave date, using _________________________ ’s official Leave-of-Absence Request Form. 2. If the leave is unexpected, you should notify your supervisor and the human resources department by filing the Leave-of-Absence Request Form as far in advance of the anticipated leave date as is practicable. (Normally, this should be within two business days of when you become aware of your need for the leave.) All _________________________ benefits that operate on an accrual basis (e.g., vacation, sick, and personal days) will cease to accrue during the leave period. You wi ll be required to use all accrued, unused vacation and personal days during the leave period. Once such benefits are exhausted, the balance of the leave will be without pay. All group health benefits (e.g., major medical, hospitalization, and dental insurance) wi ll continue during the leave provided you continue regular employee contributions to these plans. (Other benefits, such as pension, 401(k), life insurance, and long-term disability will be governe d in accordance with the terms of each benefits plan.) Employees requesting a leave to care for a covered family member with a serious hea lth condition may be required to provide medical certification from the family member's physician attesting to the nature of the serious health condition, probable length of time t reatment will be required, and the reasons that the employee is required to care for this family mem ber. Employees may also be required to provide additional physician's statements at _________________________ ’s request. Further, the family member may be required to submit to medical examination by physicians designated by _________________________ at its discretion and at _________________________ ’s expense. Leave for Employee's Serious Health Condition If you request a leave of absence for your own serious health condition, you will be granted leave under the following conditions: 1. If the leave is planned in advance, you must provide us with at least thirty days' notice prior to the anticipated leave date, using _________________________ ’s official Leave-of-Absence Form. 2. If the leave is unexpected, you should notify your supervisor and the human resources department by filing the Leave-of-Absence Request Form as far in advance of the anticipated leave date as is practicable. (Normally, this should be within t wo business days of when you become aware of your need for the leave.) 3. Any time that you expect to be or are absent for more than five consecutive work days as a result of your own serious health condition (including pregnancy), you will be required to submit appropriate medical certification from your physician. Such certification must include at a minimum, the date the disability began, a diagnosis, and the probable date of your return to work. All of _________________________ 's benefits that operate on an accrual basis (e.g., vacation, sick, and personal days) will cease to accrue during your leave period. You will be required to use all accrued, unused sick, vacation, and personal days during your leave, prior to being eligible for any benefits under _________________________ ’s salary continuation plan. Once such accrued benefits are exhausted, the balance of your leave will be without pay, unless you are eligible for short-term disability benefits in accordance with applicable state law or salary continuation in accordance with the terms of _________________________ ’s salary continuation plan. All group health benefits will continue during the leave provided you continue regular employee contributions to these plans. (Other benefits, such as pension, 401(k), life insurance, and long-term disability will be governed in accordance with the terms of each benefits plan.) During your leave, you may also be required to provide _________________________ 's with additional physician's statements on request from _________________________ or _________________________ 's insurance carriers, attesting to your continued disability and inability to work. You may also be required to submit to medical examinations by physi cians designated by _________________________ at its discretion and at _________________________ 's expense, at the beginning of, during, or at the end of your leave period, and to provide with access to your medical records as required. Before you will be permitted to return from medical leave, you will be required to present _________________________ with a note from your physician indicating that you are capable of returning to work and performing the essential functions of your position with or without reasonable accommodation. Where required, _________________________ will consider making reasonable accommodation for any disability you may have in accordance with applicable laws. Leave Entitlement Eligible employees are entitled to leave for up to twelve weeks in any twelve -month period (or longer if required by applicable state or local law or, in the case of a l eave for an employee's serious health condition, where a leave extension is requested and approved). Leave taken to care for a child after birth, adoption, or placement in your home for fost er care must be taken in consecutive workweeks. Leave taken for the employee's or a cove red family member's serious health condition may be taken consecutively, intermitte ntly, or on a reduced work/leave schedule based on certified medical necessity. In such instances, _________________________ will follow applicable federal and state laws in reviewing and approving such leave requests. Reinstatement Rights Eligible employees are entitled on return from leave to be reinstated to t heir former position or an equivalent position with equivalent employment benefits, pay, and other te rms and conditions of employment. Exceptions to this provision may apply if business circumstances have changed (e.g., if the employee's position is no longer available due to a job elimination).