Family Rights Act Information Sheet

Family Rights Act Information Sheet

This Family Rights Act Information Sheet is provided by Employer Name: to Employee Name: , whose primary work location is: . Employee Job Title: . Employment Start Date: . Effective Date of this Notice: .

Recitals

WHEREAS, Employer maintains personnel policies governing leave for qualifying events affecting employees and family members, including but not limited to birth, adoption, placement for foster care, and serious health conditions; and

WHEREAS, Employee may be eligible for unpaid leave, job protection, and continuation of group health coverage under applicable family rights laws and Employer policy for qualifying reasons; and

WHEREAS, Employer desires to provide written notice of rights and responsibilities that apply to leave taken under the Family Rights Act and related Employer procedures.

NOW THEREFORE, in consideration of the recitals and the mutual covenants contained herein, the parties agree that this Information Sheet memorializes the rights, obligations and procedures applicable to Employee under the Family Rights Act as set forth below.

1. Definitions

For purposes of this Information Sheet: "Serious health condition" means an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider; "Family member" means a spouse, child, parent, or other relation as defined by applicable law; "Intermittent leave" means leave taken in separate blocks of time or on a reduced schedule basis; "Bonding leave" means leave to bond with a newborn, newly placed adopted child, or newly placed foster child.

2. Eligibility

An eligible employee is one who has completed twelve (12) months of employment with Employer and has worked at least one thousand two hundred fifty (1,250) hours during the twelve (12) month period immediately preceding the leave request, provided that additional or different eligibility criteria in applicable state law shall also be respected where required.

3. Leave Entitlement

Subject to eligibility, Employee may be entitled to up to twelve (12) weeks of unpaid leave in a twelve (12) month period for qualifying reasons described herein. Employer shall measure the applicable twelve (12) month period by the method established in Employer policy: rolling backward from the date leave commences, calendar year, fixed 12-month period or another method. Employee acknowledges that concurrent or additional leave entitlements (paid leave, short-term disability, workers' compensation) may affect the timing and pay status of leave.

4. Qualifying Reasons and Types of Leave

Leave may be taken for the following qualifying reasons (select all that apply):

Bonding with a newborn, newly adopted child, or newly placed foster child
Employee's own serious health condition that renders the employee unable to perform the essential functions of the position
Care of a family member with a serious health condition
Qualifying exigency arising from a family member's active military duty or call to covered active duty

5. Notice and Medical Certification

Employee must provide thirty (30) days' advance notice of foreseeable leave; if thirty (30) days' notice is not practicable, notice must be given as soon as practicable. Employer may require written medical certification supporting the need for leave. Certification must be provided within fifteen (15) calendar days of Employer's request unless it is not practicable to do so. Failure to provide timely and sufficient certification may result in denial or delay of leave or designation of leave as leave without protection.

6. Intermittent and Reduced-Schedule Leave

Intermittent or reduced-schedule leave is permitted when medically necessary. Employer may require that intermittent leave for bonding be taken in whole-day increments unless otherwise required by law. Employer and Employee shall make reasonable efforts to schedule planned medical treatment to minimize disruption to operations and to allow Employer to maintain staffing requirements.

7. Benefits and Health Insurance

During approved leave, Employer will maintain group health insurance coverage on the same terms as if Employee had remained actively employed, provided Employee continues to timely pay any required employee portion of premiums. Failure to pay employee contributions may result in temporary suspension or termination of coverage as set forth in Employer policy. Upon return from leave, Employee will be restored to the same or equivalent position with equivalent pay and benefits except as otherwise permitted by law.

8. Job Restoration; Transfer; Key Employee

Upon timely return from leave, Employee will be reinstated to the same or an equivalent position. Employer reserves the right to deny reinstatement to a "key employee" as defined by applicable law where such reinstatement would cause substantial and grievous economic injury to Employer's operations; Employer will provide required written notice of such determination in accordance with law.

9. Confidentiality

Medical information and related documentation submitted in connection with leave requests will be maintained as confidential medical records separate from the employee's personnel file to the extent required by law. Access to such information will be limited to those with a need to know for legitimate business purposes.

10. Employee Obligations and Certification of Receipt

Employee is required to provide notices, certifications and periodic updates as set forth above and in Employer policy. By signing below, Employee acknowledges receipt of this Family Rights Act Information Sheet, understands the rights and obligations set forth herein, and agrees to comply with Employer's leave procedures. Employee's acceptance of this notice does not constitute a waiver of statutory rights.

11. Notices

All notices required under this Information Sheet shall be in writing and delivered to the addresses set forth below by personal delivery, certified mail, or other method reasonably calculated to provide receipt.

12. Amendments; Waiver; Counterparts

This Information Sheet may be amended only by a written instrument signed by both Employer and Employee. No waiver of any provision shall be effective unless in writing and signed by the party waiving compliance. This Information Sheet may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

13. Governing Law; Entire Agreement; Severability

This Information Sheet shall be governed by and construed in accordance with the laws of the jurisdiction controlling Employer's principal place of business, without regard to choice-of-law principles. This Information Sheet constitutes the entire written notice of Employee's rights and Employer's obligations under the Family Rights Act and supersedes any prior written notice specific to the same leave request. If any provision of this Information Sheet is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

14. Certification of Understanding

By signing below, Employee acknowledges receipt of this Family Rights Act Information Sheet, affirms that the information provided by Employee on this form is true and accurate to the best of Employee's knowledge, and understands the consequences of willfully making a false statement in connection with a leave request.

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