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1 I P a g e E m p l o y e e R e q u e s t F M L A Employee Request for Family and Medical Leave City of Belgrade Family and Medical Leave is provided under the FAMILY AND MEDICAL LEAVE ACT OF 1993. Please see the reverse side for a summary of the FMLA or contact Human Resources at [PHONE REDACTED]. I am requesting Family or Medical Leave for the following reason: The birth of a child and to care for the newborn child within one year of birth; The placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement; To care for the employee’s spouse, child, or parent who has a serious health condition; A serious health condition that makes the employee unable to perform the essential functions of his or her job; Any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on “covered active duty;” or Twenty-six workweeks of leave during a single 12-month period to care for a covered service member with a serious injury or illness if the eligible employee is the service member’s spouse, son, daughter, parent, or next of kin (military caregiver leave). Up to 12 work weeks in a 12-month period for certain family and medical reasons, and qualified exigency for an eligible active service member; up to 26 work weeks in a 12-month period for care of a covered service member with a serious injury or illness. Name (printed): Position & Location: Start Date: End Date: List approximate dates if unknown (i.e. maternity, surgery dates, etc.) Time Requested (days or weeks): Days Weeks Leave Type: Continuous Intermittent Irregular Intermittent I understand that employer contributions of insurance premiums while on unpaid Family and Medical Leave may be recovered from the employee who does NOT return to work following a period of leave under FMLA for reasons unrelated to this medical circumstance. Employee Signature & Date: Once signed, send to Human Resources in City Hall. Eligibility Requirements – to be completed by Human Resources: Hire Date: Last FMLA Used: FTE: 1.0 If Less than 1.0, need to have a minimum of .50 FTE/1040 hours FMLA Approved Yes Date approved: No, explain: Human Resources Signature & Date: Email sent to employee, supervisor and benefits: C: Payroll Original in Personnel File ---PAGE BREAK--- 2 I P a g e E m p l o y e e R e q u e s t F M L A YOUR RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT OF 1993 (Amended 01/16/2009) FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to “eligible” employees for certain family and medical reasons, and qualified exigency leave for a covered service member. Care of a covered service member with a serious illness or injury may be provided to covered employees up to 26 workweeks of unpaid leave in a 12-month period. Employees are eligible if they have worked for a covered employer for at least one year, and for 1,040 hours over the previous 12 months. REASONS FOR TAKING LEAVE: Unpaid leave must be granted for any of the following reasons: • to care for the employee’s child after birth, or placement for adoption or foster care; • to care for the employee’s spouse, child, or parent who has a serious health condition; • for a serious health condition that makes the employee unable to perform the employee’s job; • for a qualifying military exigency of the employee’s spouse, child, or parent; • to care for the employee’s spouse, child, parent or next of kin who is a covered military service member. GETTING PAID WHILE ON FAMILY MEDICAL LEAVE (FML): Family medical leave is unpaid. However, the statute provides that employees may take, or employers may require employees to take, any accrued paid vacation, personal, family or sick leave, as offered by their employer, concurrently with any FMLA leave. • You will be required to use any accrued sick leave you have at the beginning of your FMLA leave period. • Once you have exhausted your sick leave balance, you may choose to use any annual leave or comp hours that you have accrued. • The remainder of any FMLA leave will be unpaid. ADVANCE NOTICE and MEDICAL CERTIFICATION: The employee may be required to provide advance leave notice and medical certification. Leave may be denied if the requirements are not met. • The employee must ordinarily provide 30 days’ notice when the leave is “foreseeable”; • An employer may require medical certification to support a request for leave because of a serious health condition and may require second or third opinions (at the employer’s expense) and a fitness for duty report to return to work. JOB BENEFITS and PROTECTION: • For the duration of FML, the employer must maintain the employee’s health coverage, by continuing to pay the City contribution toward the Employees coverage, under any “group health plan.” • Upon return from FML, most employees must be restored to their original or equivalent positions with equivalent pay, benefits and other employment terms. • The use of FML cannot result in the loss of any employment benefits that accrued prior to the start of an employee’s leave. UNLAWFUL ACTS BY EMPLOYERS: FMLA makes it unlawful for any employer to: • interfere with, restrain or deny the exercise of any right provided under FMLA; • discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA. ENFORCEMENT: • The U.S. Department of Labor is authorized to investigate and resolve complaints of violations; • An eligible employee may bring a civil action against an employer for violations. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State, local or collective bargaining agreement which provides greater family or medical leave rights. FOR MORE INFORMATION: • Contact Human Resources at [PHONE REDACTED] • Visit http://www.dol.gov/esa/whd/fmla/