Fill - Free fillable Care For Sick Parent Child Spouse Or State Covered Relative PDF form

Revised 12/2019

Packet Updated 12/2019

YOUR NEXT STEPS

PERSONAL LEAVE OF ABSENCE

(Care for Sick Parent, Child, Spouse or State-Covered Relative)

1. Apply for time off and job protection under the Family and Medical Leave Act

(“FMLA”) if you have completed one year of service and have worked at least

1,250 hours during the 12 months before the start of your leave. Please note that

some states have their own leave laws with different eligibility requirements and

benefits. Contact HR XPRESS with any questions about your potential eligibility

and benefits under a state leave law.

•

Read the attached Employee Rights and Responsibilities under the Family

and Medical Leave Act for details.

2. Provide the attached Certification of Health Care Provider for Family Member’s

Serious Health Condition (WH-380-F) to your covered relative’s health care

provider for completion.

3. Email the completed form two weeks before the start of your leave, or as soon as

possible to loaforms@tjx.com. You or the health care provide can submit the

form, but you must ensure that HR XPRESS receives it.

Notes:

• Once HR XPRESS reviews all completed documents, we will mail you a Leave

Status Update informing you of the time off granted, as well as a Designation

Notice regarding FMLA. These notices may arrive separately.

•

Paid Family Leave benefits may also be available to associates in Rhode Island.

•

Visit www.Ripaidleave.net for additional information.

EMPLOYEE RIGHTS

UNDER THE FAMILY AND MEDICAL LEAVE ACT

Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period

for the following reasons:

• The birth of a child or placement of a child for adoption or foster care;

• To bond with a child (leave must be taken within 1 year of the child’s birth or placement);

• To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;

• For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;

• For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,

child, or parent.

An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks

of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.

An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees

may take leave intermittently or on a reduced schedule.

Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee

substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.

While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.

Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with

equivalent pay, benets, and other employment terms and conditions.

An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave,

opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.

An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must:

• Have worked for the employer for at least 12 months;

• Have at least 1,250 hours of service in the 12 months before taking leave;* and

• Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite.

*Special “hours of service” requirements apply to airline ight crew employees.

Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice,

an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.

Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine

if the leave qualies for FMLA protection. Sufcient information could include informing an employer that the employee is or

will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or

continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which

FMLA leave was previously taken or certied.

Employers can require a certication or periodic recertication supporting the need for leave. If the employer determines that the

certication is incomplete, it must provide a written notice indicating what additional information is required.

Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the

employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and

responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.

Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as

FMLA leave.

Employees may le a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit

against an employer.

The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective

bargaining agreement that provides greater family or medical leave rights.

LEAVE

ENTITLEMENTS

BENEFITS &

PROTECTIONS

ELIGIBILITY

REQUIREMENTS

1-866-4-USWAGE

www.dol.gov/whd

For additional information or to ﬁle a complaint:

(1-866-487-9243) TTY: 1-877-889-5627

U.S. Department of Labor Wage and Hour Division

THE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISION

WH1420 REV 04/16

REQUESTING

LEAVE

EMPLOYER

RESPONSIBILITIES

ENFORCEMENT

____________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

________________________________________________ ____ ____________________________________

Certification of Health Care Provider for

U.S. Department of Labor

Family Member’s Serious Health Condition

(Family and Medical Leave Act)

Wage and Hour Division

OMB Control Number: 1235-0003

Expires: 8/31/2021

SECTION I: For Completion by the EMPLOYER

INSTRUCTIO

NS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer

may require an employee seeking FMLA protections because of a need for leave to care for a covered family

member with a serious health condition to submit a medical certification issued by the health care provider of the

covered family member. Please complete Section I before giving this form to your employee. Your response is

voluntary. While you are not required to use this form, you may not ask the employee to provide more information

than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain

records and documents relating to medical certifications, recertifications, or medical histories of employees’ family

members, created for FMLA purposes as confidential medical records in separate files/records from the usual

personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies,

and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.

Employer name and contact: _______

______________________________________________________________

SECTION II: For Completion by the

EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family

member or his/her me

dical provider. The FMLA permits an employer to require that you submit a timely,

complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family

member with a serious health condition. If requested by your employer, your response is required to obtain or

retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and

sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer

must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.

Your name: ___________________________________________________________

_______________________

First Middle Last

Name of family member for whom you will provide care:______________________________________________

First Middle Last

Relationship of family member to you: _____________________________

________________________________

If family member is your son or daughter, date of bir

h:____

___

____

___

____

___

____

___

Describe care

ou will

provide to your family member and estimate leave needed to provide care:

Employee Signature Date

Page 1 CONTINUED ON NEXT PAGE

Form WH-380-F Revised May 2015

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

The TJX Companies, Inc. or its subsidiaries

HR XPRESS - 1-888-627-6299, LOA Option

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under

the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. Several questions

seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best

estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you

can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA

coverage. Limit your responses to the condition for which the patient needs leave. Do not provide information

about genetic tests, as defined in 29 C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e).

Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last

page.

Provider’s name and business address:______________________________________________________________

Type of practice / Medical specialty: ______________________________________________________________

Telephone: (________)____________________________ Fax:(_________)_______________________________

PART A: MEDICAL FACTS

1. Approximate date condition commenced: ______

___________________________________________________

Probable duration of condition: _________________________________________________________________

Was the patient admitted for an overnight stay in a hospital, hospi

ce, or residential

dical care facility

___

No ___Yes. If so, dates of admission: _______________________________________________________

Date(s) you treated the patient for condition: ______________________________________________________

Was

medication, other than over-the-counter medication, prescribed?

___

___Yes.

Will the patient need to

have treat

ent visits at least twice per year due to the condition? ___No ____ Yes

Was the patie

nt referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?

____

No ____Yes. If so, state the nature of such treatme

nts and expected duration of treatment:

2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ______________________

3. Describe other relevant medical fa

cts, if any, related to the condition for which the patient needs care (s

uch

medical facts

may include sy

mptoms, diagnosis, or any regimen of continuing treatm

ent such as the use of

specializ

ed equipm

ent):

Page 2 CONTINUED ON NEXT PAGE

Form WH-380-F Revised May 201

__________________________________________________________________________________________

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need

for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or

transportation needs, or the provision of physical or psychological care:

4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and

recovery

? ___No

___

Yes.

Estim

ate the beginning and ending dates for the perio

of incapacity

___

__________________________

During this time, will the patient need care? __ No __ Yes.

Explain the c

are needed by the patient and why such care is medically necessary:

5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes.

Estim

ate treatment schedule, if any, including the dates of any scheduled appoi

ntments and the time required for

each appointment, includi

ng any recovery

period:

Explain the c

are needed by the patient, and why such care is medically necessary: ________

________________

6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? __

Yes.

Estim

te the

hours the pati

ent needs care on an inter

ittent basis, if any

________ hour(s) per day; ________ days per week from _________________ through __________________

Explain the c

are needed by the patient, and why such care is medically necessary:

Page 3 CONTINUED ON NEXT PAGE Form WH-380-F Revised May 2015

___________________________________________________________________________________________

______________________________________________ ____________________________________________

7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily

activities?

____No ____Yes

Based upon t

he patient’s medical history

and your knowledge of t

e medical co

ndition, estimate the frequency

flare-ups and the duration

related incapacity

that the patient may have over the next 6 months (e.g., 1 epis

ode

every

3 months lasting 1-2 days

Frequency

: _____ times per _____ week(s) _____

month(s)

Duration: _____

hours or ___ day(s) per

episode

Does the patient need care during these flare-ups? ____

No ____ Y

es.

Explain the c

are needed by the patient, and why such care is medically necessary

: ________

________________

____ ___

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

Signature of Health Care Provider Date

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616;

29 C.F.R. § 825.500.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB

control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this

collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the

data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate

or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator,

Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

Page 4 Form WH-380-F Revised May 2015

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Care For Sick Parent Child Spouse Or State Covered Relative

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Care For Sick Parent Child Spouse Or State Covered Relative Form

Related forms

Fillable Care For Sick Parent Child Spouse Or State Covered Relative

Fill Online, Printable, Fillable, Blank Care For Sick Parent Child Spouse Or State Covered Relative Form

Related forms

First 20 documents completely FREE!