Fill and Sign the Fmla 497334793 Form

Employer Response to Employee U.S. Department of Labor Request for Family or Medical Leave Employment Standards Administration Wage and Hour Division (Family and Medical Leave Act of 1993) OMB NO: 1215-0181 Date:       Expires: 08-31-07 To:       (Employee’s Name) From:       (Name of Appropriate Representative) Subject: REQUEST FOR FAMILY/MEDICAL LEAVE On       , you notified us of your need to take family/medical leave due to: (Date) The birth of a child, or the placement of a child with you for adoption or foster care; or A serious health condition that makes you unable to perform the essential functions for you job: or A serious health condition affecting your spouse, child, parent, for which you are needed to provide care. Your notified us that you need this leave beginning on       and that you expect (Date) leave to continue until on or about       . (Date) Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period for the reasons listed above. Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if you 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 you return from leave. If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious heath condition which would entitle you to FMLA leave; or (2) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during you FMLA leave. 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 continued 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 you leave until the certification is submitted 4. You may elect to substitute accrued paid leave for unpaid FMLA leave. 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. (a) If you normally pay a portion of the premiums for your health insurance, these payments will continue the period of FMLA leave. Arrangements for payment have been discussed with you, and it is agreed that you will make premium payments as follows: (Set forth dates, e.g., the 10 th of each month, or pay periods, etc. that specifically cover the agreement with employee.) (b) You have a minimum 30-day (or, indicate longer period, if applicable) grace period in which to make premiums payments, If payment is not made timely, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option we may pay your share of the premiums during FMLA leave, and recover these payments form you upon your return to work. We will will not pay your share of health insurance premiums while you are on leave. (c) We will will not do the same with other benefits (e.g., life insurance, disability insurance, etc.) while you are on FMLA leave. If we do pay your premiums for other benefits, when you return from leave you will will not be expected to reimburse us for the payments made on you behalf. 6. You will will not be required to present a fitness-for-duty certificate prior to being restored to employment. If such certification is required but not received, your return to work may be delayed until certification is provided. 7 .(a) You are are not a “key employee” as described in § 825.217 of the FMLA regulations. If you are a “key employee”. Restoration to employment may be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic harm to us as discussed in § 825.218. (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 us.. (Explain (a) and/or (b) below. See §825.219 of FMLA regulations.) 8. While on leave, you will will not be required to furnish us with the 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 the form, you will will not be required to notify us at least town work days prior to the date you intend to report to work. 9. You will will not be required to furnish recertification relating to a serious health condition. ( Explain below, if necessary, including the interval between certification as prescribed in § 825.308 of the FMLA regulations) This optional use form may be use to satisfy mandatory employer requirements to provide employees taking FMLA leave with Written notice detailing specific expectations and obligations of the employee and explaining any consequences of a failure to meet these obligations. (29CFR 825.301 (b) ( Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public Burden Statement We estimate that it will take an average of 5 minutes t complete this collection of information, including the time for reviewing instructions. Searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimated or any other aspect of this collection of information, including suggestions for reducing this burden. Send them to the Administrator, Wage and Hour Division of Labor, Room S-3502. 200 Constitution Avenue, N.W., Washington D.C. 20210.