FMLA LEAVE REQUEST FORM NAME: EMPLOYEE ID #.: TITLE: DEPARTMENT: _ LEAVE DATES REQUESTED: BEGINNING DATE: ENDING DATE: REASON FOR LEAVE REQUEST: (CHECK ONE AND ANSWER FOLLOW-UP QUESTIONS) (1) the birth of a child and in order to care for that child; (2) the placement of a child for adoption or foster care; (3) to care for a spouse, child or parent with a serious health condition, which includes both physical care and psychological comfort and reassurance as a medical necessity; (4) because of the serious health condition of the employee, which makes the employee unable to perform the essential functions of his/her position. FOR NUMBERS 1 AND 2 ABOVE, PROVIDE THE FOLLOWING INFORMATION: ANTICIPATED/ACTUAL BIRTH DATE: PLACEMENT DATE: _ DOES YOUR SPOUSE WORK FOR THE CITY? IF YES, PROVIDE: NAME: SOCIAL SECURITY NUMBER: DEPARTMENT: _ DOES YOUR SPOUSE INTEND TO TAKE LEAVE DUE TO EITHER NUMBERS 1 OR 2 ABOVE? Yes No FOR NUMBER 3 ABOVE, PROVIDE THE FOLLOWING INFORMATION: NAME OF RELATION: RELATIONSHIP TO EMPLOYEE: ADDRESS OF RELATION: _ If request involves one or more children, provide birth dates: NOTIFICATION REQUIREMENT: (CHECK ONE) 30 DAYS NOTICE GIVEN BY EMPLOYEE FOR FORESEEABLE FMLA- QUALIFYING NEED. EMPLOYEE MUST PROVIDE MEDICAL CERTIFICATION BEFORE THE LEAVE BEGINS. LEAVE NOT FORESEEABLE; NOTICE GIVEN AS PRACTICABLE OR AS DIRECTED. Failure to provide timely certification may result in a denial of continuation of leave until the certification is submitted. Disciplinary action may be taken against the employee for being on unauthorized leave of absence. If the employee never produces the certification, the employee may not subsequently assert FMLA protection for the absence. REASON FOR LESS THAN 30 DAY S NOTICE:
LEAVE REQUESTED (MUST BE FOR MEDICAL NECESSITY) INTERMITTENT REDUCED WORK DAY REDUCED WORK WEEK REASON NEEDED: _ SCHEDULE OF LEAVE REQUESTED: ANTICIPATED LENGTH OF INTERMITTENT OR REDUCED WORK DAY OR WEEK: YOU ARE REQUIRED TO SUBMIT A CERTIFICATION OF MEDICAL NECESSITY COMPLETED BY YOUR HEALTH CARE PROVIDER ON THE CERTIFICATION OF HEALTH CARE PROVIDER FORM ATTACHED. NOTICE SUBMITTED BY: EMPLOYEE S SIGNATURE DATE TO BE COMPLETED BY THE PAYROLL CLERK Employee has been with City a minimum of 12 months (months do not have to be consecutive) Employee has worked at least 1,250 hours in the last 12 months preceding the date the leave is requested (using FLSA rules for actual hours worked, excludes vacation, sick leave, personal leave, jury duty leave, compensatory leave, and military leave. See Overtime/FLSA Policy, HR 4.0, Section III-C-2.) EMPLOYEE IS ELIGIBLE FOR FMLA LEAVE ON. CERTIFIED BY:, PAYROLL CLERK APPROVED/DISAPPROVED: DEPARTMENT HEAD S SIGNATURE DATE CC: Employee Director of Human Resources
C I T Y O F C O R P U S C H R I S T I R I S K M A N A G E M E N T Medical Authorization I hereby authorize any and all physicians, surgeons, and doctors who have examined, treated or x- rayed me, and all hospitals in which I have ever been a patient, to furnish the City of Corpus Christi Risk Management Department any and all records, x-rays, laboratory reports and other data of information in medical history, treatment or diagnosis, past, present and future, and permit them to examine such records, x-rays, reports and medical information, and hereby authorize you to permit them to make copies thereof. Any photo static or carbon copy of this authorization shall be considered as effective and valid as the original. Dated this day of SIGNATURE ADDRESS CITY, STATE, ZIP CODE TELEPHONE NUMBER
DEFINITIONS FOR CERTIFICATION OF HEALTH CARE PROVIDER FORM A Serious Health Condition means an illness, injury, impairment, or physical or mental condition that involves one of the following: 1. Hospital Care Inpatient care (i.e. an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity 2 or subsequent treatment in connection with or consequent to such impatient care. 2. Absence Plus Treatment (A) A period of incapacity 2 of more than three consecutive calendar days (including any subsequent treatment or period of incapacity 2 relating to the same condition), that also involves: (1) Treatment 3 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 3 under the supervision of the health care provider. 3. Pregnancy Any period of incapacity due to pregnancy, or for prenatal care. 4. Chronic Conditions Requiring Treatments A chronic condition which: (1) 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; (2) Continued over an extended period of time (including recurring episodes of a single underlying condition) 1 and (3) May cause episodic rather than a continuing period of incapacity 2 (e.g., asthma, diabetes, epilepsy, etc.). 5. Permanent/Long-term Conditions Requiring Supervision A period of incapacity 2 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 include Alzheimer s, a severe stroke, or the terminal stages of a disease.
6. Multiple Treatments (Non-Chronic Conditions) Any period of absence 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 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 2 of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis). 7. Limited Duty Assignment & Reasonable Accommodation Policy Leave under the Limited Duty Assignment & Reasonable Accommodation Policy HR 32.0 states that when an employee is unable to perform any type of work for the City, they are considered to be in a No Work Status. This status may not exceed nine (9) consecutive months. This nine-month period will run at the same time as FMLA leave. Employee must contact the Human Resources Department, (361) 826-3300 to meet with the DRC Coordinator. 1. Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave. 2. Incapacity, for purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom. 3. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or denial examination. 4. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the counter medications such as aspirin, antihistamines, or salves; or bedrest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.
CERTIFICATION OF HEALTH CARE PROVIDER (Family and Medical Leave Act of 1993) 1. Employee s Name: 2. Patient s Name: (if not the 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 1 qualify under any of the categories described? If so, please check the applicable category. Hospital Inpatient Care Absence Plus Treatment Pregnancy Chronic Condition Requiring Treatment Permanent/Long-term Condition Requiring Supervision Multiple Treatments (Non-Chronic Condition) None of the above 4. 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. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient's present incapacity 2 if different). a. Will it be necessary for the employee to work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in Item 6 below)? Yes No If yes, give the probable duration. b. If the condition is chronic, or pregnancy, state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity 2. 6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments. b. If 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. If any of these treatments will be provided by another provider of health service (e.g.; physical therapist), please state the nature of the treatments. d. If 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. If medical leave is required for the employee s absence from work because of the employee s own condition (including absence due to pregnancy or a chronic condition), is the employee unable to perform work of any kind?
Yes No b. If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee s job (the employee or the employee s Department Head should supply you with information about the essential job functions)? Yes No If yes, please list the essential functions the employee is unable to perform. c. If neither (a) nor (b) applies, is it necessary for the employee to be absent from work for treatment? Yes No 8. a. If leave 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, safety, or transportation? Yes No b. If no, would the employee s presence to provide psychological comfort be beneficial to the patient or assist in the patient s recovery? Yes No c. If the patient will need care only intermittently, or on a part-time basis, please indicate the probable duration of this need. 1. Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave. 2. Incapacity, for purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom. 3. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or denial examination. 4. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the counter medications such as aspirin, antihistamines, or salves; or bedrest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider. _ Signature of Care Provider 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, including a schedule (1) if leave is to be taken intermittently: or (2) if it will be necessary for you to work less than a full schedule. Employee Signature Date
NON-FMLA CERTIFICATION FORM BY HEALTH CARE PROVIDER 1. Employee s Name: 2. Patient s Name: (if not the 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 1 qualify under any of the categories described? If so, please check the applicable category. Hospital Inpatient Care Absence Plus Treatment Pregnancy Chronic Condition Requiring Treatment Permanent/Long-term Condition Requiring Supervision Multiple Treatments (Non-Chronic Condition) None of the above 4. 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. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient's present incapacity 2 if different). a. Will it be necessary for the employee to work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in Item 6 below)? Yes No If yes, give the probable duration. b. If the condition is chronic, or pregnancy, state whether the patient is presently incapacitated and the likely duration and frequency of episodes of incapacity 2. 6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments. b. If 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. If any of these treatments will be provided by another provider of health service (e.g.; physical therapist), please state the nature of the treatments. d. If 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. If medical leave is required for the employee s absence from work because of the employee s own condition (including absence due to pregnancy or a chronic condition), is the employee unable to perform work of any kind?
Yes No b. If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee s job (the employee or the employee s Department Head should supply you with information about the essential job functions)? Yes No If yes, please list the essential functions the employee is unable to perform. c. If neither (a) nor (b) applies, is it necessary for the employee to be absent from work for treatment? Yes No 8. a. If leave 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, safety, or transportation? Yes No b. If no, would the employee s presence to provide psychological comfort be beneficial to the patient or assist in the patient s recovery? Yes No d. If the patient will need care only intermittently, or on a part-time basis, please indicate the probable duration of this need. 1. Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave. 2. Incapacity, for purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom. 3. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or denial examination. 4. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the counter medications such as aspirin, antihistamines, or salves; or bedrest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider. _ Signature of Care Provider 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, including a schedule (1) if leave is to be taken intermittently: or (2) if it will be necessary for you to work less than a full schedule. Employee Signature Date
TO: FROM: DATE: SUBJECT: Family & Medical Leave Act (FMLA DESIGNATION FORM) This memorandum will confirm your notification of to take FMLAqualifying leave which commences on and which is expected to continue until further notice from your physician for the following reason: the birth and care of your child, or placement of a child with you for adoption or foster care; a serious health condition that makes you unable to perform the essential functions of your job; a serious health condition affecting your spouse, child, or parent for which you are needed to provide care. The status of your leave request is indicated by a check mark below: You are eligible for FMLA leave which has been approved for you effective. Either your notice of the need to use FMLA leave was given in a timely manner, or you had no foreseeable way to provide 30 days of advance notice. You are eligible for FMLA leave, but your FMLA leave has been denied for 30 days until. Since your leave was foreseeable and 30 days advanced notice was not given, your leave will begin 30 days after the date of your verbal notice to take FMLA leave which was received on. Your request for FMLA leave has been denied due to your ineligibility, or the prior usage of your entitlement of 12 work weeks in a calendar year, or for the following reason: This leave will be counted against your FMLA leave entitlement of up to 12 weeks during a 12 month period (measured backwards). If you and your spouse both work for the City, any leave taken for childbirth, placement of a child, or care of a parent shall be limited to a combined 12 weeks of leave in the 12 month period of FMLA leave for these purposes. If your leave has been denied, you may appeal it by using the Grievance Procedure within 15 days of the receipt of the denial for FMLA leave.
The following information is provided for you so that you fully understand and acknowledge your responsibilities while using FMLA leave. 1. I understand that I am required to provide within 15 days a completed Certification of Health Care Provider Form (copy attached) certifying the continuing medical necessity of my leave. I understand that if this is not provided within the 15 days from the receipt of this letter, continuation of my leave may be denied until the certification is received. I understand that should this occur, disciplinary action may be taken against me for being on unauthorized leave of absence. I understand that if I fail to return the certification, this leave will not be designated FMLA job protected leave. A copy of your job description may be attached for use by the Health Care Provider in determining your ability to perform your assigned essential functions. 2. I understand that I may be directed to obtain a second and third medical opinion from health care providers or to be recertified as provided for in the Administrative Procedure HR 8.0-AP1 and provisions of the Family and Medical Leave Act. 3. I understand that while I am on approved FMLA leave, I will be required to call you at every two weeks beginning on to report on my status and my intention to return to work. I understand that my failure to do so may result in further continuation of my leave being denied until I comply with this requirement. 4. I understand that during my leave I will be required to use my sick leave accrual, personal leave, and vacation accrual, if any, in that order. I understand that, as of the date of this memorandum, I have hours of sick leave accrual, hours of personal leave and hours of vacation accrual. 5. I understand that if my FMLA leave is due to an on-the-job injury, I will be required to supplement my workers compensation with accrued leave, if any, so that I receive my base pay equal to that received before my FMLA-eligible leave began. 6. I understand that during my use of any paid leave, payroll deductions will continue to collect my portion of the premiums for any health insurance, life insurance and disability insurance coverage I may have. 7. I understand that upon the expiration of all of my accrued leave, the remaining leave, if any, will be FMLA leave without pay. 8. I understand that I must continue to pay the employee s premium portion for any health, life or disability insurance benefits for which I am eligible. I understand that I must make those payments to be received by the Collection Section of the Finance Department by the 7 th of each month while on unpaid leave. I understand that if I am more than 45 days late with my portion of the premium payment, coverage shall be discounted for the duration of my FMLA leave.
9. I understand that upon returning to work from a FMLA leave, I will be reinstated to the same level and condition of coverage which I would have had, had I not taken the FMLA leave. I understand that I shall not be required to meet any qualification requirements, such as a new pre-existing condition waiting period, open enrollment, etc. 10. I understand that I will be required to provide medical certification to you within 30 days of any request I make to extend my leave beyond the FMLA limits of 12 work weeks within a 12 month period. 11. I understand for work related injury or illness I will be required to be released by my personal doctor and The Doctor s Center, the City's medical services provider, by undergoing a fitness-for-duty certification before I can return to work. If leave is taken for non-work related illness or injury, I must provide a release from my personal doctor before returning to work. I understand that this certification will be limited to the particular health condition which caused my need for FMLA leave. 12. I understand that if I am released to return to full duty, and my leave was less than 30 days, I shall be reinstated in my original position, if available, or in a position with equivalent status, pay, benefits, and other employment terms and working conditions. 13. I understand that while I am on FMLA leave for more than 30 continuous days, I will be required to take a drug test prior to resuming my duties. 14. I understand that if I am unable to perform the essential functions of the position I held before the leave or those of a comparable position, my medical information will be reviewed by the City's Disability Review Committee pursuant to City Policies. 15. I understand that if a reduction-in-force should occur during my leave, and my position would have been deleted had I not been on leave, that I will lose my right to reinstatement under FMLA, but will retain my rights as stated in the City's Reduction-In-Force Procedure. 16. I understand that my next performance appraisal is due, and that upon my return, I will be evaluated based on the actual time I was on duty during the rating period. 17. I understand that any fraudulent use of FMLA leave will not protect me from my job restoration or the maintenance of my health insurance benefit. I understand that any fraudulent request on my part for FMLA leave will be considered a violation of City and departmental policy and will result in termination. 18. I understand that my failure to provide medical certifications as requested and allowed under the Act may result in a discontinuance of my approved FMLA leave and may result in my receiving disciplinary action up to and including suspension or termination. 19. I understand that for intermittent FMLA leave based on medical necessity that I am responsible for consulting with my Department Head, or designee, to make a reasonable attempt to arrange the schedule of treatments or absences so as not to unduly disrupt the Department s operations, subject to approval of the health care provider.
20. I understand that any previously approved Outside Employment Request Form is invalid effective the beginning date of this FMLA-designated leave and that all outside employment must cease while I am on limited duty or no duty related to an occupational or non-occupational serious health condition unless I receive written authorization from the Citywide Disability Review Committee Coordinator in the Human Resources Department to continue the outside employment. I understand that I am responsible for resubmitting a request for Outside Employment Request Form upon being released to full duty by the City s designated physician and before resuming any outside employment. 21. I understand that I am required to contact the Human Resources Department at (361) 826-3300 to meet with the DRC Coordinator to begin my No-Work/Limited Duty Status. The status will run at the same time as the FMLA leave and shall not exceed nine months. If you have any questions or concerns regarding this memorandum or your status as your leave progresses, please call me. Department Head Department Head/Designee
ACKNOWLEDGMENT OF RESPONSIBILITIES UNDER FMLA LEAVE By my signature below, I acknowledge that I have received a copy of this memorandum regarding my responsibilities while taking FMLA leave. I understand that by signing below, I am stating that I understand its contents. By my signature I am certifying that the information given in my request for FMLA leave is true and that I agree to notify my department head if my circumstances change. Employee Signature Date CC: Director of Human Resources Employee s personnel file Assistant City Attorney, Civil Service