Fill and Sign the Field Operations Handbook Chapter 39us Department Form

FILE FORM FOR FAMILY AND MEDICAL LEAVE Employee name: Spouse employee (if applicable): Hire date: Hire date: Request for leave from to in increments of Human Resources Section Prior FMLA taken in 12-month cycle? Yes No No. days requested: No. days available: Spouse employee leave taken in same calendar year? From to Prerequisites met? Yes No If no, explain disqualification: Reason for Leave SELF FAMILY MEMBER M.D. certification received? M.D. certification required? Notice given? Notice given? Prerequisites met? Prerequisites met? ADA accommodation requested? Birth/adoption entitlement ending date: EAP drug rehab? Yes No If yes, terms and conditions of reinstatement: EAP alcohol rehab? Yes No If yes, terms and conditions of reinstatement: Type of Leave Granted Birth/adoption ending date: Intermittent (date): from to time Reduced schedule (date): from to time Regular FMLA straight time from [Start Date] to [End Date]. Specific terms or conditions of leave/reinstatement: Mandated leave under: State law Federal law Election to substitute paid leave (PTO) Yes No If yes, type: Days available: Approved type of leave: Birth/Adoption Intermittent Regular Reduced Schedule From To Authorized signature: Date: Health Benefits Does the employee participate in a health benefit plan? Yes No Current monthly contribution: Notice given on monthly contribution for continuation of benefits? Yes No Amount: Due Date: I agree to reimburse [Company] for my continued participation in the insurance benefit plan on the terms stated above. Employee Signature: Date: (If an extension of leave is requested, prepare new form and attach.)