Fillable Fmla Extended Absence (Southern Utah University)

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Fmla Extended Absence (Southern Utah University)

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FAMILY AND MEDICAL LEAVE

AUTHORIZATION FORM – Extended Absence

Employees who have worked for at least 1,250 hours during the 12-month period immediately prior to

this request for FMLA leave are eligible for FMLA leave.

Name _____________________________________________ T-Number _________________________

Department ________________________________________ Hire Date __________________________

TYPE OF LEAVE REQUESTED

Check one box:

[ ] Employee Family and Medical Leave

[ ] Extension of previously taken Employee Family and Medical Leave

Previous days taken were ___________________________

[ ] Leave to care for newborn or adopted child or child place (via state procedure) for foster care

The Leave will begin on __________________________ and end on _____________________________

Reason for Leave (list any medical conditions, etc, relating to the absence):

_____________________________________________________________________________________

REASON FOR LEAVE

I request family and medical leave for the following reason (check one box):

[ ] My personal serious health condition

[ ] Serious health condition of my child

[ ] Serious health condition of my parent

[ ] Serious health condition of my spouse

[ ] Birth of my child

[ ] Adoption of a child by me or placement of a child with me for foster care

[ ] Servicemember leave for a “qualifying exigency”

[ ] Servicemember leave to care for a family member injured in the line of military duty

I understand that this time off will be recorded as FMLA time off and count towards said time off for the

current year.

_____________________________________________

Employee Signature

_____________________________________________

Date

INSURANCE PREMIUM RECOVERY AUTHORIZATION FORM

I certify by my signature that I have read and understand the following:

I acknowledge the University’s legal right to recover the cost of any premium paid by it to

maintain my coverage in group health benefits during any period of unpaid leave under the

following conditions:

I fail to return from leave at the expiration of the leave to which I am entitled; and

The reason I fail to return to work is not one of the following:

o The continuation, recurrence, or onset of a serious health condition that entitles

me to leave to care for a child, parent or spouse with a serious health condition,

or if I am unable to perform the functions of my position due to my own serious

health condition; or

o Other conditions beyond my control prevent me from returning.

Printed Name ________________________________ T-Number _____________________

Signature ____________________________________ Date _________________________

INSURANCE PREMIUM REIMBURSEMENT AGREEMENT

I certify by my signature that I have read and agree to the do the following:

If I fail to return from leave, for any reason other than #1 and #2 above, I agree to coordinate

with the University to develop a mutually acceptable schedule to reimburse the University for

the cost of any premium paid by it to maintain my coverage in group health benefits during any

period of unpaid leave taken by me.

Printed Name ________________________________ T-Number _____________________

Signature ____________________________________ Date _________________________

LEAVE CERTIFICATION REQUIREMENTS

Section I: To request leave for the care of a child, parent, or spouse with a serious health condition

I have attached a certification from the health care provider who is treating my child, parent, or spouse.

The certification includes the following:

1. The date on which the condition commenced;

2. The probable duration of the condition;

3. The appropriate medical facts within the knowledge of the health care provider regarding the

condition;

4. An estimate of the time needed to care for the individual involved (including any recurring

medical treatment;

5. A statement that the condition warrants my participation to provide care.

Section II: To request leave for the care of any employee’s personal serious health condition.

I have attached certification from the health care provider who is treating my own serious health

condition. The certification includes the following:

1. The date on which my condition commenced;

2. The probable duration of the condition;

3. The appropriate medical facts within the knowledge of the health care provider regarding the

condition;

4. A statement that I am unable to perform the functions of my position due to my condition.

Section III: Additional certification requirements for intermittent leave or for leave on a reduced leave

schedule

In addition to the foregoing certifications from the health care provider involved, I have attached

additional information from the health care provider as stipulated below:

Leave for the employee

o A statement of medical necessity for my intermittent leave or reduced leave schedule

and the expected duration of the schedule;

o A listing of the dates of my planned medical treatment and the duration of the

treatment(s).

Leave to care for a son, daughter, spouse or parent

o A statement attesting to the necessity of intermittent leave or reduced leave for me to

provide care or to assist in their recovery;

o An estimate of the expected duration and schedule of my intermittent or reduced leave.

I certify by my signature that I have read and understand the University’s certification policy.

Printed Name ___________________________________ T-Number ________________________

Signature _______________________________________ Date ____________________________

__________________________________________________________________________________________________________________________________________________

________________________________________________ ____ ____________________________________

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

INSTRUCTIONS

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

INSTR

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

member or his/her medical provi

der. 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.

Fill out these 4 pages for an employee's FAMILY MEMBER has a serious health condition

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

Page 1 Form WH-380-E Revised May 2015

Certification of Health Care Provider for U.S. Department of Labor

Employee’s Serious Health Condition Wage and Hour Division

(Family and Medical Leave Act)

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OMB Control Number: 1235-0003

Expires: 8/31/2021

SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS 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 due to a serious health condition to submit a

medical certification issued by the employee’s health care provider. 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 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: __________________________________________________________________

Employee’s job title: _____________________________ Regular work schedule: _______________________

Employee’s essential job functions: _____________________________________________________________

__________________________________________________________________________________________

Check if job description is attached: _____

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical 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 due to your own 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. 29 C.F.R. § 825.305(b).

Your name: __________________________________________________________________________________

First Middle Last

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer,

fully and completely, all applicable parts. 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 employee is seeking

leave. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in

29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29 C.F.R. §

1635.3(b). Please be sure to sign the form on the last page.

Provider’s name and business address: ___________________________________________________________

Type of practice / Medical specialty: ____________________________________________________________

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

Fill out these 4 pages when the EMPLOYEE is the person with the health condition

Southern Utah University - Lori Ann Barnson, Benefits Manager - (435)586-7819

________________________________________________________________________________________

PART A: MEDICAL FACTS

1. Approximate date condition commenced: __________________________________

____________________

Probable duration of condition: ______________________________________________________________

Mark below as applicable:

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

ce, or residential

dical care facility

___

___Yes.

If so, dates of ad

mission:

Date(s) you tr

eated the patient for condition:

Will the patient need to have treatment visits at least twice per y

ear due to the condition? ___No ___ Yes.

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

No ___Yes.

Was the patient referred to other health care provider(s) for evaluation or treatm

nt (e.g.,

phy

ical therapist)

____

_Yes

. If so, state the nature of such treatments and expected duration of treatment:

2. Is the medical condition pregnancy? ___

No ___Yes. If so, expected delivery date: ____________________

3. Use the information provided by the em

ployer in Section I to a

swer this question. If the

ploy

er fail

s to

provide a list

of the em

ployee’

s essential

functions or a

job descripti

on, answer these questions based upon

the employee’s own description of his/her job functions.

Is the employee unable to perform any of his/her job functions due to the condition: ____ No ____ Yes.

If so, identify the job functions the em

ployee is unable to perform:

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave

(such medical facts may inc

lude symptoms, diagnosis, or any regimen of continuing treatment such as the use

of specialized equipment):

Page 2 CONTINUED ON NEXT PAGE

Form WH-380-E Revised May 2015

____________________________________________________________________________________

__________________________________________________________________________________________

PART B: AMOUNT OF LEAVE NEEDED

5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,

including any time for treatment and recovery? ___No ___Yes.

If so, estim

ate the beginning and ending dates for the period of incapacity: _______________________

6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced

schedule because of the employee’s medical condition? ___No

___Yes.

If so, are the treatments or the reduced number of hours of work m

edically

necessary?

___No ___Yes.

Estimate treatment schedule, if any, including

the dates of any scheduled appointments and the time

required for each appointment, including any recovery period:

Estimate the part-time or reduced work schedule the e

ploy

ee needs, if any

____

___

___ hour(s) per d

___

days per week fro

m _____________ through _____________

7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job

functions? ____No ____Yes.

Is it medically necessary for the employee to be a

bsent from work during the flare-ups?

____

Yes

. If so, explain:

Based upon the patient’s medical history and

your knowledge of t

he medical condition, estimate the

frequency of flare-ups and the duration of related incapacity that the patient may

have over the next 6

months (e.g., 1 episode every 3 months lasting 1-2 days):

Frequency : _____ times per _____ week(s) _____ month(s)

Duration: _____ hours or ___ day(s) per episode

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH

YOUR ADDITIONAL

ANSWER.

Page 3 CONTINUED ON NEXT PAGE

Form WH-380-E Revised May 2015

__________________________________________________________________________________________

__________________________________________ __________________________________________

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 co

llection of information unless it displays a currently

valid OMB

control num

ber. The Department of Labor estimates that it will take an average of 20 minutes for respondents to comple

te this

collection of infor

mation, including the time for reviewing instructions, searching existing data sources, gathering and mainta

ining

the data neede

d, and completing and reviewing the collection of information. If you have any comments regarding this burde

esti

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

to the

ministrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Wa

shington, DC

20210. DO NOT SEN

D COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIEN

Page 4

Form WH-380-E Revised May 2015

LEAVE REQUEST WHEN EMPLOYEE & SPOUSE BOTH WORK FOR SUU

Check the leave being requested:

___________ Family & Medical Leave to care for a newly arrived child

___________ Family & Medical Leave to care for a parent with a serious health condition

I have a spouse employed at the University:

Spouse’s Name _____________________________ T-Number _____________________

Department _______________________________ Hire Date _____________________

I certify by my signature that I have read the following and agree to abide by it –

In any case in which a husband and wife are:

Both employed by Southern Utah University;

Both entitled to leave;

If the leave is taken for the birth or adoption of a child or to care for the serious health

condition of a parent;

then the aggregate number of workweeks of leave to which both may be entitled is limited to

twelve (12) workweeks during any 12-month period.

If there is a change in circumstances with respect to the above, I will notify the University

immediately.

Printed Name ________________________________ T-Number _____________________

Signature ____________________________________ Date _________________________

____ _ ___

____ _ ___ _

____________________________________________________________________________ ____________________________________________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ ________

______________________________________________________________________________________________________________________

Notice of Eligibility and Rights & U.S. Department of Labor

Responsibilities

Wage and Hour Division

(Family and Medical Leave Act)

OMB Control Number: 1235-0003

Expires: 8/31/2021

In general, to be eligible an employee must have worked for an employer for at least 12 months, meet the hours of service requirement in the 12

months preceding the leave, and work at a site with at least 50 employees within 75 miles. While use of this form by employers is optional, a

fully completed Form WH-381 provides employees with the information required by 29 C.F.R. § 825.300(b), which must be provided within

five business days of the employee notifying the employer of the need for FMLA leave. Part B provides employees with information

regarding their rights and responsibilities for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).

[Part A – NOTICE OF ELIGIBILITY]

TO: _________

____________

___________________

Employee

FROM: _________ _______________________________

Employer Representative

DATE: _________ _______________________________

On _____________________, y

ou informed us that you needed leave beginning on ________________

_______ for:

_____ The birth of a child, or placement of a child with you for adoption or foster care;

_____ Your own serious health condition;

_____ Because you are needed to care for your ____ spouse; _____child; ______ parent due to his/her serious health condition.

_____ Because of a qualifying exigency

arising out of the fact that your ____ spouse; _____son or daughter; ______ parent is on covered

active duty or call to covered active duty status with the Armed Forces.

_____ Because y

ou are the ____ spouse; _____son or daughter; ______ parent; _______ next of kin of a covered servicemember

with a

serious injury or

illness.

This Notice is to inform you that you:

_____ Are eligible for FMLA leave (S

ee Part B below for Rights and Responsibilities)

_____ Are not eligible for FMLA leave, because (onl

y one reason need be checked, although you m

ay not be eligible for other reasons):

_____ You have not

met the FMLA’s

12-

nth lengt

h of service require

ent. As of the first date o

f requested leav

e, you will

have worked approximately ___ months towards this requirement.

_____ You have not met the FMLA’s hours of service requirem

ent.

_____ You do not work and/or report

to a site with 50 or more employees within 75-miles.

If you have any questions, contact ___________________________________________________ or view the

FMLA poster located in

_________________________________________________________________________.

[PART B-RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE]

As explained in Part A, you meet the eligibilit y requirements for taking F MLA leave and still have FMLA leave available in the applicable

12-month period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must return the

following information to us by ____________________

_______________. (If a certification is requested, employers must allow at least 15

calendar days fr

om receipt of this notice; additi

onal time may be required in some circumstances.) If sufficie

nt information is not provided in

a timely

manner, your leave may be denied.

____ Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to support your

request ____is/____ is not enclosed.

____ Sufficient documentation to establish the required relationship between you and your family member.

____ Other information needed (such as documentation for military family leave): ________________________________________________________

____ No additional information requested

Page 1 CONTINUED ON NEXT PAGE Form WH-381 Revised February 2013

Lori Ann Barnson, Benefits Manager

____ _ ___ _

__________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _

If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave (only checked blanks apply):

____ Contact _____________________________________ at ___________________________ to make arrangements to continue to make your share

of the premium payments on y our health insurance to maintain health benefits while you are on leave. You have a minimum 30-day (or, indicate

longer period, if applicable) grace period in which to

make premium payments. If payment is

not made timely, your group health insurance may be

cancelled, provide

d we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your

share of the premiums during FMLA leave, and recover these payments from you upon your return to work.

____ You will be required to use your available paid ______ sick, _______ vacation, and/or ________other leave during y

our FMLA absence. This

means that you will receive your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave

entitlement.

____ Due to your status within the company, you are considered a “key

employee” as define

d in the FMLA. As a “key employee,” restoration to

employment may

be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us.

We ___have/____ have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous

economic harm to us.

____ While on leav

e you will be required to furnish us with periodic reports of your status and intent to return to work every __________

____________.

(Indicate interval of periodic reports, as appropriate for the particular leave situation).

If the circumstances of your leave change, and you are able to return to wo

rk earlier than the date indicated on the this form, you will be required

to notify us

at least two workdays prior to the date you intend to report for work.

If your leave does qualify as

FMLA leave you will have the following rights while on FMLA leave:

• You have a right under the FMLA for up to 12 week

s of unpaid leave in a 12-month period calculated as:

_____ the calendar year (January – December).

_____ a fixed leave year based on _______________________________________________________________________________________.

_____ the 12-month period measured forward from the date

of your first FMLA leave usage.

_____ a “rolling” 12-month period measured backward from the date of any FMLA leave usage.

• You have a right

under the FMLA for up to 26 weeks of unpaid leave in a single 1

2-month period to care for a covered servicemember with a serious

injury or illness. This single 12-month period commenced on ________________________________________________________________________.

• Your health benef

its must be maintained during any period of unpaid leave under the same conditions as if you continued to work.

• You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from

FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not

have return rights under FMLA.)

• If you do not return to work following FMLA leave for a reason other than: 1) the continuation, recurrence, or onset of a serious health condition which

would entitle you to FMLA leave; 2) the continuation, recurrence, or onset of a covered servicemember’s serious injury or illness which wo

uld entitle

you to FMLA leave; or 3) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums

paid on your behalf during your FMLA leave.

• If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA leave entitlement, you have the right to have

____ sick, ____vacation, and/or ___ other leave run concurrently with your unpaid le

ave entitlement, provided you meet any applicable requirements

of the leave policy. Applicable conditions related to the substitution of paid leave are referenced or set forth below. If you do not meet the requirements

for taking paid leave, you remain entitled to take unpaid FMLA leave.

____For

a copy of conditions applicable to sick/vacation/other leave usage please refer to ____________ available at: ___________________________.

____Applicable conditions for use of paid leave:_____________________________________________

______________________________________

Once we obtain th

e information from you as specified above, we will inform you, within 5 business days, whether your leave will be designated as

FMLA leave and count towards your FMLA leave entitlement. If you have any questions, please do not hesitate to

contact:

_______________________________________________at ______________________________________.

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

It is mandatory for employers to provide employees with notice of their eligibility for FMLA protection and their rights and responsibilities. 29 U.S.C. § 2617; 29

C.F.R. § 825.300(b), (c). It is mandatory for em

ployers to retain a copy of this disclosure in their recor

ds 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 10 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 THE COMPLETED FORM TO THE WA

AND HOUR DIVISION.

Page 2 Form WH-381 Revised February 2013

Lori Ann Barnson, Benefits MGr

435-586-7819

✔

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Fmla Extended Absence (Southern Utah University)

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Completed 23 July 2020

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