Winnebago County Application for leave under the Federal and Wisconsin Family and Medical Leave Act (FMLA)

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1 Winnebago County Application for leave under the Federal and Wisconsin Family and Medical Leave Act (FMLA) Directions for completion of forms: EMPLOYEE REQUEST FOR LEAVE complete all sections on the front and back of this sheet pertaining to your request for leave. You must be sure to fill in the start date of your leave, including any absences that have already occurred, which you consider part of the leave you are requesting. **BE SURE TO SIGN AND DATE THE BACK SIDE OF THE APPLICATION AND ALSO HAVE YOUR SUPERVISOR SIGN AND DATE THE APPLICATION.** This form must be returned to the Human Resources Department. CERTIFICATION OF PHYSICIAN OR PRACTITIONER complete all sections on the front of this form pertaining to your request for leave. This form must then be given to your medical provider for completion of the form s back side. **BE SURE YOUR MEDICAL PROVIDER SIGNS AND DATES THE BOTTOM OF THIS FORM AFTER THEY HAVE FILLED IN THE APPROPRIATE SECTIONS.** This form should then be returned to the Human Resources Department; or it can also be faxed to , which is a secure fax machine in the Human Resources Department. CALENDAR complete this calendar if you are taking intermittent leave or leave longer than one week. Return this completed form with your application to the Human Resources Department. COMPARISON & DEFINITION SHEETS general information regarding FMLA for your reference. If you have any questions, please call Ext The Law Allows Employees 15 Days From The Date They Receive The Forms To Complete And Return All Completed FMLA Application Paperwork To Their Employer For Review. EACH EMPLOYEE IS RESPONSIBLE FOR HAVING THEIR FORMS COMPLETED CORRECTLY AND RETURNED TO THE HUMAN RESOURCES DEPARTMENT WITHIN THE 15-DAY TIMEFRAME.

2 WINNEBAGO COUNTY EMPLOYEE REQUEST FOR LEAVE UNDER THE FEDERAL AND WISCONSIN FAMILY AND MEDICAL LEAVE ACT To be eligible for Family/Medical Leave, you must have been employed with Winnebago County at least 12 months and worked at least 1,000 hours to qualify for the State Leave or worked at least 12 months and at least 1,250 hours to qualify for the Federal Leave. Employee Name: Position: Department: Date of Hire: Hours Per Week: Hours Per Day: Shift: Please indicate below your work schedule by providing the number of hours per day and the days you work for a two week period: Week 1 Sun Mon Tue Wed Thu Fri Sat Week 2 Sun Mon Tue Wed Thu Fri Sat This Leave request is under the State and/or Federal law. If you qualify for Federal and State Family/Medical Leave, the leave used counts against your entitlement under both laws. FAMILY LEAVE Birth of a child - Date or expected date of birth Adoption of a child - Date of placement of child Foster care (Federal Leave only) - Date of placement of child Care for a child with a serious health condition Care for a spouse with a serious health condition Care for a parent with a serious health condition Length of leave requested (include date leave will begin): Leave will be unpaid Leave will be paid as follows (list each day off with pay type/unpaid): Describe the nature of your family members serious health condition: (OVER)

3 MEDICAL LEAVE Your own serious health condition Length of leave requested (include date leave will begin): Leave will be unpaid Leave will be paid as follows (list each day off with pay type/unpaid): Describe the nature of your serious health condition: Please have your health care provider complete the attached medical certification form stating the medical facts concerning the Family or Medical leave requested. Employee Signature: Date: Department Head/Supervisor Acknowledgment *If Dept. Head is requesting leave, County Executive must acknowledge Signature Date FMLA Form (7/08)

4 . CERTIFICATION OF PHYSICIAN OR PRACTITIONER Return completed form in a sealed envelope, marked personal and confidential, to: Winnebago County Human Resources Department 448 Algoma Blvd, Oshkosh, WI (or via fax to (920) ) EMPLOYEE/PATIENT INFORMATION AND INFORMED CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION Employee's Name: Social Security Number: Employee's Address: City, State, Zip: Telephone Number: Patient's Name: Patient's Age: Relationship to Employee: HIPAA-COMPLIANT AUTHORIZATION TO RELEASE INFORMATION: By completing this document, I demonstrate my informed consent and authorization to allow the physician or practitioner identified on the back of this form to release and disclose to Winnebago County Human Resources Department such health care records and information concerning my current medical condition as is necessary to support my request for a leave of absence and/or any additional benefits the employer may provide. This authorization is made per my request. This authorization shall be valid for two (2) years from the date shown below, unless revoked by me in writing at an earlier date. Although I understand that I may revoke this authorization in writing at any time, I also understand that any such revocation will not apply to any information that has already been released in reliance on this authorization, and that any revocation may have an adverse effect on the receipt of employer-provided benefits. I understand that my medical treatment is not conditioned upon me providing this authorization. I understand that if this authorization is for the release of psychotherapy notes I will complete a separate authorization for any other health information. I understand that information disclosed by the physician or practitioner to the employer may be subject to redisclosure and not protected by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). Employee Signature: Date: Alternatively, signature of Personal Representative and statement of authority to act on behalf of individual: Date: IF PATIENT IS ADULT FAMILY MEMBER OF EMPLOYEE: Patient Signature: IF PATIENT IS MINOR CHLD: Signature of Parent or Guardian: Date: Date: EMPLOYEE'S STATEMENT REGARDING LEAVE TO CARE FOR A FAMILY MEMBER When Family Leave is needed to care for a seriously-ill family member, you must explain the care you will provide and an estimate of the time period during which this care will be provided, including a schedule if leave is to be taken intermittently or on a reduced leave schedule: Employee Signature: Date: (OVER)

5 Medical Facts Regarding Patient's Condition: Date condition commenced: Last day worked: STATEMENT OF PHYSICIAN OR PRACTITIONER Probable duration of condition: Date expected to return to work: Is (or was) patient incapacitated (unable to work, attend school, or perform regular daily activities)? Yes No Please provide dates of incapacity: If patient remains incapacitated, how long is incapacitation expected to last? If the patient's condition is of a chronic nature, please describe likely frequency and duration of periods of incapacity: Regimen of treatment to be prescribed. (Indicate number of visits, general nature and duration of treatment, including referral to other provider of health services. Include schedule of visits or treatment if it is medically necessary for the employee to be off work on an intermittent basis or work less than the employee's normal schedule of hours per day or days per week.): By physician or practitioner: By another provider of health services: IF EMPLOYEE IS PATIENT, PLEASE COMPLETE THIS SECTION. Yes No Did employee's condition arise out of employment? Yes No Is/was inpatient care of the employee required? If yes, dates: Yes No Is/was employee able to perform all of the functions of employee's regular position? (Answer after reviewing statement from employer of essential functions of employee's regular position, or if none provided, after discussing with employee.) If no, dates: Yes No If employee is currently unable to perform all of the functions of employee's regular position, is employee able to perform work of any kind? (If yes, please describe in comments section below, including the dates such restrictions are expected to last.) IF EMPLOYEE'S FAMILY MEMBER IS PATIENT, PLEASE COMPLETE THIS SECTION. Yes No Is/was inpatient care of the family member (patient) required? If yes, dates: Yes Comments: No Did/will the patient require assistance for basic medical, hygiene, nutritional needs, safety or transportation? (If yes, please describe in the comments section below, including dates.) PHYSICIAN OR PRACTITIONER INFORMATION Physician Name: Address: City, State, Zip: Telephone: Field of Specialty: License No.: Physician Signature: Date: YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT. IF YOU DO NOT RECEIVE A COPY, PLEASE ASK FOR IT.

6 COMPARISON OF THE WISCONSIN AND FEDERAL FAMILY AND MEDICAL LEAVE ACTS FEDERAL WISCONSIN Effective Date April, 1988 Eligible Employee 1. Worked 12 months and 1. Worked 12 months and 2. Worked 1,250 hours 2. Worked 1,000 hours Types/Amount of Leave 12 workweeks per year for: 1. 6 workweeks for birth or 1. Birth of a child adoption of a child 2. Placement for adoption/ 2. 2 workweeks to care for foster care child, spouse or parent 3. Care for child, spouse or with a serious health parent with a serious health condition, and condition 3. 2 workweeks for your own 4. Your own serious health serious health condition condition When are Leaves Calendar year Calendar year available? Paid or Unpaid? An eligible employee may elect Leaves are generally unpaid or an employer may require unless it is the option of substitution of any accrued paid the employee to substitute vacation, personal or family paid leave which has been leave for birth/placement of a accrued by the employee. child or care for child, spouse or parent with a serious health cond. An employee may elect or an employer may require substitution of accrued paid vacation, personal, medical or sick leave to care for a child, spouse or parent with a serious health cond. or care for your own serious health cond. Nothing in this title shall require an employer to provide paid sick leave or paid medical leave in any situation in which such employer would not normally provide any such paid leave. Intermittent Leave Intermittent and reduced schedule leave Family and Medical leave may (non-continuous) and not permitted for birth or adoption unless be taken on a non-continuous reduced schedule leave approved by the Director of Human basis. Reduced schedule leave (reduced hours per day Resources. When medically necessary, may be taken for Family or week) intermittent or reduced schedule leave may Medical leave equal to the be taken for the employee' s own serious shortest increment permitted by health condition or that of the employee' s the County for any other nonfamily member. This is subject to emergency leave. This is medical certification. subject to medical cert. (OVER)

7 Medical Certification Yes Yes Form If an employee is returning from If an employee is returning their own leave, he/she must provide from their own leave, he/she a return to work certification from must provide a return to work the health care provider. certification from the health care provider. Health Insurance ** Maintain same level Maintain same level **If you end your employment during or within 30 days after your Family/Medical leave or you do not return to full-time status upon your return, the County will recover the health insurance premiums paid (County portion) during the time of leave, subject to State and/or Federal law, unless there are extenuating circumstances which prohibit you from returning. Reinstatement Same job or equivalent Same job or equivalent position position Notice to Employer 30 days advance notice if 30 days advance notice if foreseeable, otherwise as foreseeable, otherwise as soon as possible soon as possible This is a general overview of the Family and Medical Leave laws. Specific questions should be directed to the Winnebago County Human Resources Department.

8 DEFINITION OF SERIOUS HEALTH CONDITION FOR FMLA PURPOSES One of the most significant changes in the final FMLA regulations concerns the definition of serious health condition. For purposes of the FMLA, an employee of a FMLA covered employer is entitled to FMLA leave to care for a spouse, parent or child with a serious health condition or in the event of the employee s own serious health condition. The interim regulations defined a serious health condition as an illness, injury, impairment, or physical or mental condition that involves either inpatient care or continuing treatment. (Additionally, FMLA leave is available for the birth or adoption of a child or placement in the home by foster care; however, those provisions were not modified by the final FMLA regulations.) Although the final FMLA regulations maintain the serious health condition requirement, the definition of a serious health condition has been expanded. The final regulations have been amended to ensure that leave is available for chronic conditions such as asthma and diabetes that may require periods of absence lasting less than three days and where no visit to a health care provider is needed. Accordingly, a serious health condition means an illness, injury, impairment, or physical or mental condition that involves one of the following: Inpatient care in a hospital, hospice or residential medical care facility, or any period of incapacity or subsequent treatment in connection with such care. A period of incapacity of more than three consecutive calendar days that also involves continuing treatment by a health care provider. Incapacity due to pregnancy or prenatal care. Incapacity or treatment for a chronic serious health condition that requires periodic visits for treatment by or under the direct supervision of a health care provider, continues over an extended period, and may involve occasional periods of incapacity (such as asthma, diabetes, epilepsy). Permanent or long-term incapacity due to a condition for which treatment may be ineffective and which required the continuing supervision of, but not necessarily active treatment by, a health care provider (for example, severe stroke, Alzheimer s, terminal stages of disease). Absences to receive multiple treatments by or under the supervision, orders, or referral of a health care provider for either restorative surgery after an accident or injury or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days without such treatment. Any period of recovery relating to the above continuing treatments. This does not include such things as the common cold, flu, upset stomach, chicken pox, etc.

9 2009 WINNEBAGO COUNTY FAMILY AND MEDICAL LEAVE REQUEST EMPLOYEE: **Please mark the actual dates of your request: DEPT: X= Scheduled RTW= Return to work date January 2009 February 2009 March April 2009 May 2009 June July 2009 August 2009 September October 2009 November 2009 December