District 2 Public Health

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1 District 2 Public Health Family Medical Leave Policy No. 220 Effective Date: July 1, 2013 Revised Date: District 2 Public Health County Boards of Health (CBH) References: I. Purpose 1. Federal Family and Medical Leave Act (FMLA) 29 USC 2601 et seq. 2. U. S. Department of Labor 29 CFR Part Rule 23 of the State Personnel Board Family leave is job-protected leave from work that is available to eligible employees for qualifying reasons. Federal law entitles eligible employees a maximum of 12 workweeks of family leave during any 12 month period per FMLA 29USC 2601 et seq. II. Scope This policy applies to all employees of the County Board of Health (CBH) and the attached agencies who meet the eligibility requirements specified in this policy. III. Qualifying Reasons Page 1 of 24 Family Leave may be used by an eligible employee for any of the following reasons: (Section A) Birth of Employee s Child (Section B) Adoption or Foster Care The birth of the employee's child, and to care for the newborn child; NOTE: Any period of incapacity due to pregnancy or continuing treatment for prenatal care is considered a serious health condition and would qualify for family leave. The placement of a child with the employee for adoption or foster care, and to care for the child after placement; (See Section IV. ELIGIBILITY)

2 (Section C) Serious Health Condition The employee's serious health condition which makes the employee unable to perform the essential functions of the position; or Care of the employee's child, spouse or parents who have a serious health condition. For a qualifying exigency arising out of the fact that the employee s spouse, son, daughter, or parent is on active duty or call to active duty status as a member of the National Guard or Reserves in support of a contingency operation. For an eligible employee who is a spouse, son, daughter, parent, or next of kin of a current member of the Armed Forces, including a member of the National Guard or Reserves, with a serious injury or illness up to a total of 26 workweeks of unpaid leave during a single 12-month period to care for the service member. NOTE: "Child" includes: biological, adopted or foster child, stepchild, legal ward, or for whom the employee stands in loco parentis who is either under age 18 or age 18 or older and incapable of self-care because of mental or physical disability. "Parent" includes biological parent or an individual who stands or stood in loco parentis to an employee. "Parent" does not include parents "in law." "In loco parentis" means having day-to-day responsibilities to care for and financially support a child. IV. Eligibility (Section A) In order to be eligible for family leave, employees must: 1. Have been employed with State government for a minimum of 12 months (the 12 months do not need to be consecutive; there can be a break in service); 2. Have been present at work for a minimum of 1,250 hours during the 12 months immediately before the beginning of family leave (does not include holidays or (time away from work on paid or unpaid leave); and 3. Have a qualifying reason for taking family leave. Page 2 of 24

3 (Section B) Eligibility for Family Leave due to Birth of a Child Eligibility for family leave due to the birth of a child begins on the date of birth and ends 12 months after the date of birth. (See Section V. A. SERIOUS HEALTH CONDITION). (Section C) Family Leave due to Placement of a Child for Adoption or Foster Care Eligibility for family leave due to the placement of a child with the employee for adoption or foster care may begin prior to the date of placement if absence from work is needed for the placement to proceed. Eligibility ends 12 months after the date of placement. (Section D) Limitations to Family Leave for Serious Health Condition Family leave for a serious health condition is limited to the time determined to be medically necessary by the health care provider. (Section E) Eligibility of Family Leave for both Husband and Wife When both husband and wife are eligible CBH employees, they are limited to a combined total of 12 work weeks of family leave in a calendar year for the following reasons: 1. Care of the employee's parent with a serious health condition; EXAMPLE: If a married couple works for State government and the wife uses six weeks of family leave to care for her mother with a serious health condition, her husband is limited to using six weeks of family leave to care for his father with a serious health condition during the same 12 month period. 2. Birth of the employee's child, or to care for the child after birth; or 3. Placement of a child for adoption or foster care with the employee, or to care for the child after placement. 4. Each spouse is entitled to use the difference between the amount of family leave he or she has taken individually for one of the above reasons and the 12 work week maximum for other qualifying reasons. Page 3 of 24

4 V. Definitions (Section A) Serious Health Condition A serious health condition is defined as an illness, injury, impairment, or physical or mental condition that involves: 1. Inpatient care in a hospital, hospice, or residential medical care facility, including any period of incapacity or any further treatment in connection with the inpatient care; or 2. Continuing treatment by a health care provider which includes any one or more of the following: a. A period of incapacity of more than three consecutive calendar days and any additional treatment or period of incapacity relating to the same condition that also involves: (1) treatment two or more times by a health care provider, by a nurse or physician s assistant under direct supervision of a health care provider, or other referred health care services provider, or (2) treatment by a health care provider at least once which results in a regimen of continuing treatment (e.g., prescription medication) under the supervision of the health care provider; b. Any period of incapacity due to pregnancy or for prenatal care; c. Any period of incapacity or treatment due to a chronic serious health condition which requires periodic treatment, continues over an extended period of time, and may cause episodic rather than continuing periods of incapacity (e.g., asthma, diabetes, migraines, etc.); d. Any period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective (e.g., Alzheimer s disease); e. Any period of absence to receive multiple treatments (including recovery period) either for restorative surgery after an accident or other injury or for a condition that would likely result in incapacitation of more than three calendar days if Page 4 of 24

5 (Section B) Health Care Provider (Section C) "Intermittent Leave" not treated (e.g., chemotherapy for cancer, dialysis for kidney disease, etc.). NOTE: Substance abuse may meet the criteria for a serious health condition. Family leave may be taken for substance abuse treatment or to care for a child, spouse or parent who is receiving substance abuse treatment. Family leave for substance abuse treatment does not prevent the CBH from taking appropriate employment action against an employee. A health care provider includes the following: 1. Doctors of medicine or osteopathy; 2. Podiatrists, dentists, clinical psychologists, and optometrists; 3. Chiropractors (limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist); 4. Nurse practitioners, nurse-midwives, and clinical social workers; 5. Christian Science practitioners listed with the First Church of Christ, Scientist in Boston, Massachusetts; 6. Health care providers listed above who practice in a country other than the United States. Intermittent leave in taken in separate blocks of time due to a single qualifying reason (e.g., morning sickness, prenatal examinations). (Section D) "Reduced leave schedule" Is regularly scheduled leave which reduces an employee's normal work hours per week or per day. Page 5 of 24

6 (Section E) Qualifying Exigencies Issue arising from a covered military member s short notice deployment (i.e., deployment on seven or less days of notice) for a period of seven days from the date of notification; Military event and related activities, such as official ceremonies, programs, or events sponsored by the military or family support or assistance programs and informational briefings sponsored or promoted by the military, military service organizations, or the American Red Cross that are related to the active duty or call to active duty status of a covered military member; Certain childcare and related activities arising from the active duty or call to active duty status of a covered military member, such as arranging for alternative childcare, providing childcare on a non-routine, urgent, immediate need basis, enrolling or transferring a child in a new school or day care facility, and attending certain meetings at a school or a day care facility if they are necessary due to circumstances arising from the active duty or call to active duty of the covered military member; Making or updating financial and legal arrangements to address a covered military member s absence; Attending counseling provided by someone other than a health care provider for oneself, the covered military member, or the child of the covered military member, the need for which arises from the active duty or call to active duty status of the covered military member; Taking up to five days of leave to spend time with a covered military member who is on short-term temporary, rest and recuperation leave during deployment; Attending to certain post-deployment activities, including attending arrival ceremonies, reintegration briefings and events, and other official ceremonies or programs sponsored by the military for a period of 90 days following the termination of the covered military member s active duty status, and addressing issues arising from the death of a covered military member;any other event that the employee and employer agree is a qualifying exigency. Page 6 of 24

7 (Section F) Covered Service Member A covered service member is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the service member medically unfit to perform his or her duties for which the service member is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary disability retired list. VI. Time Frames (Section A) Allowance up to 12 Weeks of Unpaid Family/Medical Leave Eligible employees are allowed up to 12 weeks of unpaid family/medical leave during any rolling 12-month period, measured backward from the first day of each approved family/medical Leave in accordance with the Family and Medical Leave Act. (Section B) 12 Work Weeks of Family Leave Based on the Employee s Regular Work Schedule The 12 work weeks of family leave are based on the employee's regular work schedule. For example, full-time employees who regular work five days per week will be charged one work week of family leave for every five days absent from work. Similarly, parttime employees who regularly work three days per work week will be charged one workweek of family leave for every three days absent from work. NOTE: If a holiday(s) occurs during a week of family leave, the holiday(s) counts towards family leave as if it were a work day. VII. Procedures (Section A) Notice Information regarding family leave and procedures for filing complaints of violations is included in the attached Employees Rights and Responsibilities under the Family and Medical Leave Act, WHD Publications 1420 Revised January CBH organizational units are to post the notice in prominent locations where notices to employees are customarily displayed. Page 7 of 24

8 (Section B) Request Employees arc responsible for notifying their supervisors of the need for family leave. 1. The employee must give his/her supervisor adequate notice (usually 30 calendar days) when family leave is foreseeable. 2. When a 30-day notice is not possible, the employee must give his/her supervisor notice as soon as the employee becomes aware that family leave is necessary. NOTE: Approval of family leave may be delayed when adequate notice is not provided. 3. Employees needing family leave for foreseeable medical treatment (including intermittent/reduced schedule leave) must make a reasonable effort to schedule the leave so as not to unduly disrupt the operations of the work unit, subject to the approval of the employee's health care provider. (Section C) Forms 1. When requesting family leave, the employee must provide a completed FAMILY LEAVE REQUEST Form to his/her supervisor, unless submitting this form is not possible. The following information must he provided; a. Beginning and ending dates of family leave, b. Election to use accrued annual, sick, or personal leave, as appropriate, or to use leave without pay; and c. Reason for the family leave. NOTE: The reason for the leave must be explained in order to determine whether the leave qualifies for family leave. 2. The employee must provide documentation verifying child birth, adoption or foster care, as appropriate, if the absence from work is due to the birth of a child or placement for adoption or foster care. Page 8 of 24

9 3. The employee must provide a CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE completed by the attending health care provider, if the absence is due to a serious health condition of the employee or a family member. NOTE: When a single serious health condition requires multiple absences morning sickness, asthma), a CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE is not required for each absence. a. When family leave for a serious health condition is foreseeable, the certification should he provided before the absence begins. b. When it is not possible to provide this certification before family leave begins, the employee must provide it within 15 calendar days of the date it is requested. c. An employee on family leave due to a serious health condition may be required to provide certification of the serious health condition on a reasonable basis. Recertification cannot be required more often than every 30 calendar days. 4. Supervisors are to immediately forward the request and all documentation regarding family leave to Human Resources/District Personnel Department. (Section D) Response 1. The Human Resources/District Personnel Department will be responsible for the following: a. Reviewing the request to determine if the employee meets the eligibility requirements for family leave; b. Verifying that the appropriate certifications are attached; c. Recommending approval or denial of the request; and d. Verifying the employee's leave balances for use while on family leave. 2. The Human Resources/District Personnel Department will respond to family leave requests in writing within two Page 9 of 24

10 workdays, unless there are extenuating circumstances or as soon as practicable, SPB Rule 23. a. Approval notices must specify the terms and conditions of the family leave and advise employees of their right to return to work. Terms and Conditions: If the request is approved, a notice of approval should be provided explaining: 1. That the leave will count against the employee s rolling 12 month Family and Medical Leave entitlement; 2. Any requirements for furnishing medical certification and the consequences for failing to do so; 3. The employee s right to substitute paid leave and any conditions related to the substitution; 4. Any requirements for making premium payments to maintain health benefits, the arrangements for making such payments, and the consequences for failing to do so; 5. Any requirements for presenting fitness for duty certificates prior to returning to work; and 6. The employee s right to restoration to the same or equivalent job upon return from leave. Reference SPB Rule 23. b. Denial notices must include the reason that the family leave was not approved. c. If sufficient information is not available to determine whether family leave should be approved, Human Resources/District Personnel Department may conditionally approve family leave contingent upon receiving required certification. (1) If the request is based on a serious health condition, the conditional approval notice is to include a statement that a completed CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE Form must be submitted to the Office of Human Resources within 15 calendar days. (2) When the required certification is received, the employee must be advised if the family leave is approved or denied. Page 10 of 24

11 (3) If the required certification is not provided, the absence will not qualify for family leave. d. If timely notice is not provided to the employee, family leave may only be charged from the date the notice was actually provided to the employee. NOTE: The period of absence before the untimely notice is provided cannot be counted against the 12 work weeks of family leave, but the employee is protected by the provisions of the Federal Family Leave law for the entire period of absence that qualified for family leave. (Section E) Completion of Personnel Action Request Form Supervisor Responsibility Supervisors must complete the REQUEST FOR PERSONNEL ACTION Form to the Office of Human Resources/District Personnel Department to place the employee on family leave with and/or without pay. VIII. Designating Leave as Family Leave (Section A) Responsibility of Management to Designate Family Leave When Determined Appropriate It is the responsibility of management to designate family leave when determined appropriate. Employees may be placed on family leave even when they do not submit a request. (Section B) Family Leave Determined Appropriate Supervisors and/or Human Resources/District Personnel Department staff are to make this designation as soon as they determine family leave is appropriate. Supervisors and/or human resources staff may learn that an absence or part of an absence, from work qualifies for family leave either during or after the period of leave. In these circumstances, family leave may be designated as follows: 1. When supervisors and/or human resources staff learn that an employee is eligible for family leave during a period of leave, any portion of the absence from work which qualifies for family leave may be designated as such if the employee is given timely notice. Page 11 of 24

12 a. Timely notice means notifying the employee that the absence will be counted as family leave within two work days after learning that family leave is appropriate, unless there are extenuating circumstances or as soon as practicable. b. If timely notice is not provided to the employee, family leave may only be charged from the date the notice was actually provided to the employee. NOTE: An employee on annual leave advises her supervisor that she has been hospitalized and will be incapacitated for three weeks. The supervisor waits until two weeks later to notify Human Resources/District Personnel Department that the qualifying part of the absence should be counted as family leave. Human Resources/District Personnel Department sends out a notice to the employee. Based on the Federal Family Leave law, family leave may only be charged from the date the notice is provided to the employee. 2. Absences from work may only be retroactively designated as family leave after an employee has returned to work under the following circumstances: a. When supervisors and/or human resources staff learn the reason for the leave after an employee has returned to work; and b. The employee is notified within two workdays of returning that the leave will count as family leave. NOTE: When the reason for leave is known beforehand (e.g., birth of a child), employees may not be retroactively placed on family leave after returning to work. IX. Pay Status and Benefits (Section A) Use of Accrued Leave Employee may choose to use accrued leave to continue to receive pay during a period of family leave, take leave without pay, or use a combination of both to cover the absence from work with supervisory approval. Use of accrued leave must comply with CBH Page 12 of 24

13 policies on use of accrued leave (e.g., sick leave can only be used for reasons that qualify for sick leave). NOTE: FLSA compensatory time cannot be counted toward the 12 workweeks of family leave. (Section B) Employee Maintaining Health Insurance Coverage while on Family Leave While on family leave, employees who have health insurance benefits through the State Health Benefit Plan are entitled to maintain this health insurance coverage at the employee rate. NOTE: If premiums change while the employee is on family leave, he/she is responsible for paying the new premium amounts. (Section C) Maintaining Health Insurance through Flexible Benefits In order to maintain health insurance and any benefits through the Flexible Benefits Program (e.g., Accidental Death and Dismemberment Insurance, Dental Insurance, etc.), employees on family leave with pay (those using accrued leave) continue to pay premiums through payroll deductions. (Section D) Cost for Maintaining Health Insurance will be Advised Employee on family leave without pay will be advised of the cost for maintaining health insurance and any benefits through the Flexible Benefits Program, the arrangements for making payment, and the consequences for not making timely payments. 1. Employees on family leave without pay must complete and submit the following forms to the Office of Human Resources/District Personnel Department, as appropriate, to continue health insurance benefits: a. REQUEST TO CONTINUE HEALTH BENEFITS DURING LEAVE OF ABSENCE WITHOUT PAY (Form MS66-003), and b. DISABILITY CERTIFICATION (Form MS66-005), if appropriate. Page 13 of 24

14 2. Employees with at least one year of participation in the Group Term Life Insurance program under the Employees' Retirement System (ERS) may retain coverage while on family leave without pay. A request to continue coverage must be made to ERS using the ELECTION TO CONTINUE GROUP TERM LIFE INSURANCE WHILE ON LEAVE WITHOUT PAY (Form GTLI- 11) prior to beginning the family leave without pay. Coverage terminates if this written request is not received by ERS. X. Intermittent/Reduced Leave Schedule (See Section V. Definitions) (Section A) Family Leave Intermittent or on a Reduce Leave Schedule Family leave may be taken intermittently or on a reduced leave schedule when medically necessary or to provide care or psychological comfort to a qualifying family member with a serious health condition. (Section B) Family Leave after the Birth of a Child or Placement of a Child for Adoption or Foster Care Family leave after the birth of a child or placement of a child for adoption or foster care may be taken intermittently or on a reduced leave schedule only with supervisory approval, unless the absence involves a qualifying serious health condition. (Section C) Actual Amount of Leave Taken on an Intermittent or Reduced Leave Schedule Only the amount of leave actually taken on an intermittent or reduced leave schedule basis may be counted toward the 12 workweeks of family leave. For example, an employee who normally works five days per workweek and takes off one day for intermittent family leave will be charged 1/5 workweek of family leave. Similarly, a full-time employee who reduces a workweek from 40 to 20 hours is charged 1/2 workweek of family leave. (Section D) Requesting Employee Family Leave on an Intermittent or Reduced Leave Schedule Temporary Transfer Employees who request family leave on an intermittent or reduced leave schedule basis may be required to temporarily transfer to an Page 14 of 24

15 available alternative position that better accommodates recurring periods of absence. 1. The alternative position must have equivalent pay and benefits, but is not required to have equivalent duties. 2. Employees must not be transferred to alternative positions in order to discourage the use of family leave or to positions that represent a hardship. 3. When the need for intermittent leave or a reduced leave schedule ends and the employee is able to return to a normal work schedule, he/she must be returned to his/her former position or an equivalent position. XI. Return to Work (Section A) Employee Conditions An employee who has complied with the terms and conditions in the family leave approval notice is entitled to return to the same position, or an equivalent position with the same pay and grade, benefits, and comparable working conditions, at the expiration of family leave. 1. An employee does not retain this entitlement if, at the expiration of family leave, he/she is unable to perform the essential functions of the position, with or without reasonable accommodation, due to the employee's physical or mental condition. 2. An employee on family leave has no greater rights to return to work than if he or she had remained at work. For example, employees who are on family leave during a Reduction In Force (RIF) do not have a right to return to work if they are laid off due to the RIF. (Section B) Personal Serious Health Condition An employee returning from family leave due to a personal serious health condition must submit a return-to-work statement from the attending health care provider prior to returning to work. The statement must certify that the employee can perform the essential functions of the position with or without reasonable Page 15 of 24

16 (Section C) Responsibility accommodation. This statement may be a hand written note from the physician or the employee may choose to utilize the Return to Work form, either is acceptable as long as the note states whether or not the employee is released to return to work with or without accommodations. NOTE: Employees who do not provide such a required statement should not be allowed to return to work. Supervisors are to submit a completed REOUEST FOR PERSONNEL ACTION Form to the Office of Human Resources/District Personnel Department for employees returning from family leave. A copy of the return-to-work statement, if applicable, should be attached to the form. XII. Record Keeping and Questions (Section A) Record Retention (Section B) Employee Rights All family leave related employment records must be maintained for at least three years and made available upon request to the U.S. Department of Labor. These include, but are not limited to, the following; 1. Correspondence between the employee and supervisor and/or the Human Resources/District Personnel Department staff regarding family leave; 2. Records of any dispute regarding designation of leave as family leave; and 3. Any documents describing employee benefits or CBH policies and practices regarding taking of paid and unpaid leave. Employees who believe that their rights under the Family and Medical Leave Act have been violated may file a complaint with the U.S. Department of Labor, Page 16 of 24

17 (Section C) Questions Questions regarding family leave should be directed to the Office of Human Resources/District Personnel Department. ATTACHMENTS: Family Leave Notice Your Rights Under the Family and Medical Leave Act of 1993 Family Leave Request Form Documentation of Child Birth, Adoption or Foster Care Certification of Serious Health Condition for Family Leave Release to Return to Work Approved by Date Page 17 of 24

18 Your Rights Under The Family and Medical Leave Act of 1993 FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for certain family and medical reasons. Employees are eligible if they have worked for a covered employer for at least one year for 1,250 hours over the previous 12 months, and if there are at least 50 employees within 75 miles. 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, son or daughter, or parent, who has a serious health condition; or for a serious health condition that makes the employee unable to do the employee s job At the employee s or employer s option, certain kinds of paid leave may be substituted for unpaid leave. Advance Notice and Medical Certification: The employee may be required to proved advance leave notice and medical certification. Taking of leave may be denied if requirements are not met. The employee ordinarily must provide 30 days advance 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 a second or third opinion (at the employer s expense) and a fitness for duty report to return to work. Job Benefits and Protection For the duration of FMLA leave, the employer must maintain the employee s health coverage under any group health plan. U.S. DEPARTMENT OF LABOR EMPLOYMENT STANDARDS WAGE and HOUR DIVISION Washington, D.C Page 18 of 24 Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. The use of FMLA leave cannot result in the loss of any employment benefit that is 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 employer for violations. FMLA does not affect any Federal or state law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights. For Additional Information: Contact the nearest office of the Wage and Hour Division, listed in most telephone directories sunder U.S. Government, Dept of Labor. WH Publication 1420 June 1993

19 County Board of Health FAMILY LEAVE REQUEST Employee Name (Last, First, MI) Employee ID # Street Address Apartment/Box/RR# City, State, Zip Code Telephone Number (Include Area Code) Division Section/Unit Supervisor Employee s Job Title HOME: WORK: REASON FOR FAMILY LEAVE REQUESTED I hereby request use of Family Leave from to for one of the following reasons: Birth of my child and/or care for my newborn child Attach DOCUMENTATON OF CHILD BIRTH, ADOPTION, OR FOSTER CARE Adoption or foster care of a child and/or care of the child after placement with me Attach DOCUMENTATION OF CHILD BIRTH, ADOPTION, OR FOSTER CARE Care of my (circle one) child, spouse or parent who has a serious health condition Attach CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE A serious health condition (as defined in CBH Policy 220) which renders me unable to perform my essential job functions Attach CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE A qualifying exigency (as defined in CBH Policy 220). Attached documentation of qualifying exigency. Attach CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE NOTE: Use of family leave for any combination of circumstances listed above is limited to a 12 month period. Return to your former position or equivalent position with the same pay grade, benefits and comparable working conditions is contingent upon compliance with the terms of family leave. Please complete the following: LEAVE USAGE I am requesting to use the indicated number of hours of accrued leave during the period of absence: hours of annual leave hours of sick leave hours of personal leave I am requesting that hours be charged to leave without pay during the period of absence. I am requesting that my previously approved Family Leave be extended through. Employees Signature Date SUPERVISOR S RECEIPT I received this leave request on It is being sent to Human Resources on Print The original Supervisor s of this Name form and appropriate documents should Signature: be submitted to your supervisor, who will forward your request to the Office of Human resources for review. Please retain copies of all information for you records. Page 19 of 24

20 County Board of Health DOCUMENTATION OF CHILD BIRTH, ADOPTION OR FOSTER CARE RE: TO: Name of Employee Name of Attending Health Care Provider or Name of Agency or Attorney DATE: Please complete one of the following: This is to certify that the employee named above is expected to become a biological parent on Date This is to certify that the employee named above became a biological parent on Date This is to certify that a child will be placed for adoption or foster care with the employee named above on Date This is to certify that a child was adopted or accepted in a foster home by the employee named above on Date Date Signature of Attending Health Care Provider (no stamps, please) or Signature of Attorney or Signature of Agency Representative Page 20 of 24

21 C ounty Board of Health CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE 1.Employee s Name [Please Print] To Be Completed By Employee 2. Patient s Name (if other than self) [Please Print] 3.Reason for taking leave: 4.If the reason for taking leave is to care for a family member with a serious health condition, state the care you will provide and an estimate of the time period during which this care will be provided. Include a schedule if leave is to be taken intermittently or on a reduced Leave schedule. Employee's Signature Date To Be Completed By The Attending Health Care Provider 5. The attached sheet describes what is meant by a Serious Health Condition under the Family and Medical Leave Act. Under which category does the patient's condition qualify? A. B. C. D E. F. None 6. Please describe the medical facts, which support your certification, including a brief statement as to how the medical facts meet the criteria of one of the above categories. 7, Approximate date the condition commenced: 8. Probable duration of condition and incapacity: 9. Will it be medically necessary for the employee to be off work on an intermittent basis or to work less than the employee's normal schedule of hours per day or days per week as a result of the condition (including treatment)? If yes, please give probable duration. 10. If the condition is chronic (see condition D) or pregnancy, please state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity. Page 21 of 24

22 County Board of Health CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE 11. If additional treatment will be required for the condition, provide an estimate of the probable number of such treatments and, if applicable, the interval between such treatments, actual or estimated dates of treatment (if known), and any period required for recovery. If any of these treatments will be provided by another provider of health care services (e.g., a physical therapist), please state the nature of these treatments. 12. If a regimen of continuing treatment is required under your supervision, please provide a general description of such regimen (e.g., prescription drugs, therapy requiring special equipment, etc.). If this certification relates to the employee's personal serious health condition, complete items 13 and 14 below. Otherwise, please skip to item Is the employee above to perform work of any kind? (If '`No'', skip item 14) O Yes O No 14. Is the employee able to perform the essential functions of the position? O Yes O No (Answer after reviewing statement from employer describing essential functions of the position, or, if none provided, after discussing with employee.) For certification relating to care of employee's family member, complete items 15 through Does (or will) the patient require assistance for basic medical, hygiene, nutritional needs, safety, or transportation? O Yes O No 16. After reviewing the employee's signed statement (see item 4 on pg. 1), is the employee's presence necessary or beneficial for the patient's care? (This may include psychological comfort.) O Yes O No 17. Please estimate the period of time care is needed or the employee's presence would be beneficial: Signature of Health Care Provider (no stamps, please) Date Type of Practice Address Telephone Number Page 22 of 24

23 County Board of Health Family and Medical Leave RELEASE TO RETURN TO WORK Name of Employee is released to return to work on. Date With no work-related restrictions OR With the following work-related restrictions: Duration of restrictions: Name of Attending Health Care Provider Please Print Type of Practice Signature of Attending Health Care Provider Phone Number Date Page 23 of 24

24 County Board of Health ATTACHMENT TO CERTIFICATION OF SERIOUS HEALTH CONDITION FOR FAMILY LEAVE FORM A Serious Health Condition under the Family and Medical Leave Act means an illness, injury, impairment, or physical or mental condition that involves one of the following: A. Inpatient Care (i.e., an overnight stay) in a hospital, hospice or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care. B. Absence From Work Plus Treatment - A period of incapacity of more than three (3) consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition that also involves: Treatment two (2) or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment (e.g., prescription drugs) under the supervision of the health care provider. C. Pregnancy - Any period of incapacity due to pregnancy or continuing treatment for prenatal care. D. Chronic Condition Requiring Treatment - A chronic condition which; Requires periodic visits for treatment by a health care provider, or by a nurse or physician's assistant under direct supervision of a health care provider; Continues over an extended period of time (including recurring episodes of a single underlying condition); and May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.). E. Permanent/Long-Term Condition Requiring Supervision - A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples: Alzheimer's disease, severe stroke, the terminal stages of a disease, etc. F. Multiple Treatments (Non-Chronic Conditions) - Any period of absence to receive multiple treatments (including any period of recovery there from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three (3) consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis), etc. Page 24 of 24

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