(Attachment A) anew York City Transit New York City Transit Authority Staten sland Rapid Transit Operating Authority Manhattan & Bronx Surface Transit Operating Authority REQUEST AND NOTFCATON FOR FAMLY AND MEDCAL LEAVE DEPARTMENT: RC NO.lDVSON:.. DATE: _ NAME: ~ ~ TTLE: ROO: _ PASS NO:_. ~ _ SOCAL SECURTY NO: ---''-- _ 1. REASON FOR REQUESTNG FMLA LEAVE: My own serious health condition renders me unable to perform the functions of my position. The birth of a child and in order to care for such a child. The adoption of a child or placement of a child for foster care. Serious health condition of your: child, spouse, parent. 2. Requested Absence from the Authority From:, 20 (A.M./P.M.) To:, 20 (A.M./P.M.) Total No. of days: _ ntermittent Leave -. -----.;""'- ~ --,. 3. understand that if the leave requested is for my own serious health condition or that of a family member, must provide medical certification within 15 calendar days of completing this form and that my failure to do so will result in denial of my leave until such certification is provided. The medical certification must be submitted to Occupational Health Services, Attention: Compliance and Support Unit, 180 Livingston Street, Room 4023, Brooklyn, New York 11201. 4. understand that may be required to submit additional certification at least once every 30 calendar days as requested by the Authority and that failure to comply with this request within 15 days may result in the Authority denying continuation of my leave. 5. f this leave is requested for the birth, adoption or placement of a foster child, agree to provide the Authority with the appropriate documentation substantiating such request within 15 calendar days of completing this form. 6. understand that, unless am notified otherwise, this leave will be counted against my annual Family and.' Medical Leave entitlement. 7. understand that when taking FMLA leave, the Authority will require that use all applicable paid leave. Such paid leave will be counted against my annual Family and Medical leave entitlement of 12 weeks.
Page 2 8. f currently make contributions for my health benefits, understand that the Authority will continue to make these contributions on my behalf and deduct such payments from my wages upon my return from FMLA leave. understand that if fail to return to work after my leave, may be liable for payment of health' insurance premiums paid by the Authority during my FMLA leave. 9. f my leave request is for my own serious illness, understand that will be required to provide the Authority with a certification from my health care provider that am physically able to return to work. 10. understand that when return from FMLA leave, the Authority will place me in the same position or an equivalent position to the one in which am presently employed. 11. understand that a fraudulent FMLA request will subject me to immediate dismissal'. 12. understand that while am on FMLA leave may not apply for or receive Unemployment nsurance Benefits. 13. acknowledge that have received a copy of this form for my records. Acknowledged: ~ Pass No: _ Employee's Signature Supervisor Date (f in an emergency situation, information received by:) Name: Title: Date: _ Request Acknowledged/Approved/Denied (circle one) Deputy Medical Director Date Department Head Date [FMLA FORM.doc)
" Certification of Physician or Practitioner (Family and Medical Leave Act of 1993) nstructions: To be completed by Practitioner or Physician ~ PLEASE PRNT CLEARY 1. Employee '1Name 2. Patient's Name (if other than employee) 3. The attached sheet describes what is meant by a "serious health condition" under the Family and Medical Leave Act. Does the patient's condition qualify under any of the categories described? f so, please check the applicable category. (1) 0 (2) 0 (3) 0 (4) 0 (5) 0 (6) 0 DNone of the above 4. Please state the diagnosis and describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories. 5. Date condijion commenced ~ -'-- _ a. Probable duration of condition (and also the probable duration of the patients' present incapa,ity2 if different) b. Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in tem 6 below)? f yes, give the probable duration.' G. f the condition is a chronic condition+condition 4) or pregnancy, state whether the,...-. patient is presently incapacitated and the likely duration and frequency of episodes of. ~ mcapactty 6. a. f additional treatments will be required for the condition, provide an estimate of the probablf number of such treatments. b. f the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any. _ c. f any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the treatments. 1 Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave. 2 "ncapacity" for purposes offmla, is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefor, or recovery therefrom.
'- Continuation Employee'sName Patient's Name (if other than employee) d. f a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g., prescription drugs, physical therapy requiring special equipment). 7. a. f medical eave is required for the employee's absence from work because of the employee's own condition (including absences due to~egnanst.. or a chronic condition), is the employee unable to perform work of any kind? U Yes UNo What are the medical conditions that interfere with the employee performing their assigned duties: b. f able to perform some work within their title please list the functions the employee is able to perform. r-_-...., 1r - -,, ~~. c. f neither a: nor b. applies, is it necessary for the employee to be absent from work for treatment? 0 Yes 0 No 8. a. fleave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation? 0 Yes 0 No b. fno, would the employee's presence to provide psychol~cal comfort be beneficial to the patient or assist in the patient's recovery? 0 Yes UNo c. f the patient will need care only intermittently or on a part-time basis, please describe the kind of care and indicate the probable duration of this need for care by the family member (i.e., the employee).
Continuation Employee's Name Patient's Name (if other than employee) have examine~ above information is correct. (Name) and hereby certify that the (please print Ylur first and last name) (Signature of Health Care Provider & Date) (Type of Practice) (Address} (Telephone number) To be completed by the employee needing family leave to care for a family member: State the care you will provide and an estimate of the period during which care will be provided. nclude a schedule of date(s) and time(s) you will require leave ifleave is to be taken intermittently or if it will be necessary for you to work less than a full schedule. (Employee's signature & Pass #) (Date) VOLUNTARY CONSENT, give permission for a health care provider representing the New York City Transit Authority, to contact the health care provider that signed my Family Medical Leave Act Medical Certification form, for the purpose of clarifying and/or validating authenticity of the medical certification. Any such inquiry pursuant to this authorization may not seek additional information regarding my health condition or that of a family member. (Employee's signature & Pass #) (Date)
A "Serious H. alth Condition" means an illness, injury impairment, or physical or medical condi ion that involves one of the following: 1. Hospit Care npatient 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 uch inpatient care. 2. Absen e Plus Treatment (a) A period of incapacity of more than three consecutive calendar days (including any subsequent 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 by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or (2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment.' under the supervision of the health care provider. 3. Pregn ncy Any period of ncapacity due to pregnancy, or for prenatal care. 4. Chron c Conditions Requiring Treatments A chronic con ition which: (1) equires periodic visits for treatment by a health care provider, or by a urse or physician's assistant under direct supervision of a health care rovider; (2) Continues over an extended period of time (including recurring episodes f a single underlying condition); and (3) ay cause episodic rather than a continuing period of incapacity (e.g., sthma, diabetes, epilepsy, etc.). 1 "ncapacity", fo, purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily acti ities due to the serious health condition, treatment therefor, or recovery therefrom. 2 Treatment inclu es examinations to determine if a serious health condition exists and evaluations of the condition. Treat ent does not include routine physical examinations, eye examinations or dental examinations. 3 A regimen of co tinuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or ther py requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does no include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-res, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care pr vider.
5. Perm neat/long-term Conditions Requiring Supervision A period of in apacity' which is permanent or long-term due to a condition for which treatment maylnot be effective. The employee or family member must be under the continuing SURrerViSionof, but need not be receiving active treatment by, a health care provider. Exa pes include Alzheimer's, a severe stroke, or the terminal stages of a disease. 6. MultiBle Treatments (Non-Chronic Conditions) Any period oflabsence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referrr i 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 thre l consecutive calendar days in the absence of medical intervention or treatment, suc~ as cancer (chemotherapy, radiation, etc.) severe arthritis (physical therapy), kidnly disease (dialysis). NOTE: Ordinarily, unless complications arise, the common cold, the flu, ear aches, upset stfmach, minor ulcers, headaches other than migraines, routine dental or orthodontia pr blems, periodontal disease, etc., are examples of conditions that DO NOT meet the defini ion of a serious health condition and DO NOT qualify for Flvll.A leave.
Your Rights under the Family and Medical.,... :....,.:.... 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 t ey have worked for their employer for at least one ear, and for 1,250 hours over Unpaid leave must be gra ted 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' spouse, son or daughter, or parent who has a seriou health condition; or. for a serious health condition that makes the employee unable to perform the employee's job. At the employee's or employer's option, certain kinds of paid leave may be substit ted for unpaid leave. The employee may be reqj1ired to provide advance leave notice and medical certifidation. Taking of leave may be.. denied if requirements are not met. The employee ordinaril must provide 30 days advance notice when the leave is "foreseeable." An employer may requir medical certification to support a request for lea e because of a serious health condition, and may requi e second or third opinions (at the employer's expense) nd a fitness for duty report to return to work. For the duration offml maintain the employee's "group health plan." leave, the employer must ealth coverage under any Leave Act '..,,. -" of 1993. the previous 12 months, and if there are at least 50 employees within 75 miles. The FMLA permits employees to take leave on an intermittent basis or to.. work a reduced schedule under certain circumstances. 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 accrued prior to the start of an employee's leave. 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. 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 or local law or collective bargaining agreement which provides greater family or medical leave rights. f you have access to the nternet visit our FMLA website: http://~,,'v.dol.gov/esa/whd./fmta.to locate your nearest Wage-Hour Office, telephone our Wage-Hour toll-free information and help line at 1-8664USWAGE (1-866-487-9243): a customer service representative is available to assist you with referral information from 8am to 5pm in your time zone; or log onto our Home Page at http://www.wagehour.dotgo.v. *U.S. GOVERNMENT PRNTNG OFFCE 2001-476-344/49051