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MEMORAN DUM (City of Allentown)

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MEMORAN DUM
TO:
ALL EMPLOYEES
FROM:
DIRECTOR, HUMAN RESO
URCES
, SAFETY & RISK
FMLA POLICY PER THE
PERSONNEL POLICY MAN
UAL
DATE:
20 JUNE
2019
A. FAMILY AND MEDICAL LEAVE ACT (“FMLA”)
The City of Allentown recognizes that it sometimes may be difficult for employees to balance
the demands of a job with personal and family needs. The Family Medical Leave Act of 1993
(“FMLA”) requires certain employers to allow eligible employees to take up to 12 weeks of
leave (paid and/or unpaid) to care for a newborn or newly adopted child, to recuperate from
their own serious illness, or to care for a seriously ill family member. For purposes of this
policy, “family members” include: (1) the employee’s spouse, (2) the employee’s parent, (3)
the employee’s natural or adopted child or dependent stepchild. For FMLA purposes, the year
shall begin on the first date FMLA leave is taken.
An eligible employee is one who has at least 12 months of service with the City of Allentown
and has worked at least 1,250 hours for the City during the previous 12-month period.
Eligibility is determined at the time the employee requests the leave.
An employee of the City of Allentown who has worked for the City for at least one (1) year, and
for one thousand two hundred fifty (1,250) hours over the previous twelve (12) months, and
works at a worksite which employees fifty (50) or more employees within seventy-five (75)
miles, is eligible for leave under the Act. Spouses, both of whom are employed by the City of
Allentown, are limited to a total of twelve (12) weeks of leave between them, in any twelve
(12) month period, except in circumstances where either spouse or their child is affected by a
qualifying serious health condition.
Your twelve (12) weeks of leave may be taken intermittently or your weekly schedule may be
reduced in hours, only if written approval from the City of Allentown is given. If you need
intermittent or reduced leave schedules due to a medical necessity, your request may be
accommodated, provided you make every effort to schedule your absences so as to minimize
the impact on the City of Allentown business operations.
Eligible Conditions: Family and medical leave may be requested for:
•
Birth, adoption, or foster care – A new parent or foster parent may apply for leave within
one year after child is born or placed in the parent’s home. If both parents work for the
City of Allentown, they will be entitled to a total of 12 weeks between them.
•
The employee’s serious health condition, as defined by the law.
•
A family member’s serious health condition, as defined by law.
•
For qualifying exigencies arising out of the fact that the employee’s spouse, child or
parent is on active duty or call to active duty status as a member of the National Guard
or Reserves in support of a contingency operation.
A covered employer also must grant an eligible employee who is a spouse, child, parent, or
next of kin of a current service member of the Armed Forces, including a member of the
National Guard or Reserves, with a serious injury or illness up to a total of 26 workweeks of
unpaid leave during a “single 12-month period” to care for the service member.
Use of Paid leave Prior to FMLA Leave: For non-bargaining unit and SEIU employees, leave
time will run concurrent with Family medical leave. However, for Police and Firefighters
leave time will not run concurrent and employees will be allowed to take the 12 week family
medical leave after leave time has been exhausted, if requested by the employee, in writing.
If an employee requests leave under FMLA because of his/her own serious health condition,
the employee must first use his/her accumulated sick leave, accumulated vacation days and
any accrued vacation or personal days. If an employee requests leave to care for an adopted
child with a serious health condition, he/she must first use accumulated vacation and personal
days and any accrued vacation days. If these days are fewer than 12 weeks required under the
law, the City will grant additional days without pay but with paid medical benefits provided by
the Act to a total of 12 weeks.
FMLA leave taken because of an employee’s serious health condition shall not be considered
when calculating occasions of sick leave used. During the term of FMLA leave, employees will
accrue seniority, sick leave, vacation leave and personal days.
Prior Notice and Authorization: The City of Allentown requires that you provide the City with a
thirty (30) days’ advance notice when FMLA leave is needed, if your need is foreseeable.
Otherwise, you must provide the City of Allentown with as much notice as is possible. The City
may delay the taking of foreseeable FMLA leave until 30 days after the required notice is
provided if these conditions are not met. If you are taking leave for personal illness or the
illness of a family member, the City of Allentown requires that you submit medical
certifications from a healthcare provider. When you request such leave, we will provide you
with the appropriate forms.
Forms: When the City receives a medical certification indicating that the employee has a
serious health condition and will be on medical leave for longer than five (5) days, the
employee will be notified in writing that medical leave will be charged to the yearly
entitlement under the provisions of the FMLA.
The employee will be required to provide medical certification of a serious health condition to
the City of Allentown in accordance with FMLA and as will be further explained to the employee
requesting FMLA leave at the time of such request. When an employee requests such leave, the
City will provide the employee with the appropriate forms. The Department of Labor-
Certification of Health Care Provider form must be completed by a healthcare professional (see
definition below) and returned within 15 days following the request.
While on FMLA leave, employees are requested to report periodically to the City every 30 days
regarding the status of the medical condition and their intent to return to work.
In accordance with our uniform medical leave of absence policy, if you take FMLA leave for
personal illness, the City of Allentown will also require a medical certification, on a City of
Allentown Medical Certification form, indicating whether you are able to return without
restrictions or unable to return from leave due to your health condition. Restoration may be
denied until such certification is provided.
Return from FMLA Leave: At the conclusion of FMLA leave, most employees will be restored to
their original or equivalent positions with the equivalent pay, benefits and other terms and
conditions of employment. The City of Allentown is not obligated to restore any employee
whose job position has been eliminated during the leave period. The City of Allentown reserves
the right to deny restoration to certain highly compensated employees if necessary to avoid
substantial and grievous economic injury to the City of Allentown’s operations. These “key”
employees are among the ten percent (10%) most highly compensated employees and will be
notified of their status as “key” employees at the time they make their request for family
medical leave. If it is anticipated that it may be necessary to deny restoration to a “key”
employee, the City of Allentown will notify that employee and offer him/her an opportunity to
return to work. If that employee elects not to return to work, the City of Allentown will
nevertheless reconsider at the end of the leave period whether or not it will be possible to
reinstate that employee without suffering substantial and grievous economic injury.
Health Care Coverage: During the period of your FMLA leave, the City of Allentown will
continue your health care coverage as if you were continuously employed. Failure to make
timely co-payments, for those required, may result in the termination of your health care
coverage. Provisions for the payment of your health care co-payments will be made at the
time of your leave request. The use of FMLA leave will not affect your exempt status under the
Fair Labor Standards Act if you are already considered exempt. If you fail to return to work at
the conclusion of your leave period, you are obligated to repay the City of Allentown the cost
of your health care premiums paid for by the City during the period of your leave.
Other Terms and Conditions: The City of Allentown will not interfere with, or restrain or deny
the exercise of any right provided under the FMLA. We will not discharge or discriminate
against any person for opposing any practice made unlawful by the FMLA nor will we
discriminate against or discharge any person because of involvement in any proceeding under
or related to the FMLA. The Secretary of Labor is authorized to investigate and attempt to
resolve complaints of violations and may bring an action in any federal or state court against a
company for violating the FMLA. The FMLA will be enforced by the Department of Labor’s
Wage and Hour Division. An eligible employee may also bring a civil suit for violations of the
FMLA. It should be noted that the FMLA does not affect any federal or state law prohibiting
discrimination, nor does it supersede any state or local law which provides for greater family
medical leave benefits. The FMLA does not affect an employer’s obligation to provide greater
leave benefits if that is required under a collective bargaining agreement or employment
benefit plan or contract. No rights provided for under the FMLA may be diminished or waived
by the agreement, plan or contract. A copy of your rights under the FMLA is posted at the City
of Allentown, and we are always happy to answer any questions concerning the FMLA or other
concerns you may have as an employee. When FMLA is requested, we will provide you with a
summary of your rights and obligations, and the expectations that we have of you in exercising
leave. If an employee should find that an additional leave of absence is needed at the end of
the FMLA leave period, that employee should feel free to contact the City of Allentown Human
Resource Department. Requests for additional leave of absence will be handled on an
individualized basis.
TERMS:
Healthcare provider: A FMLA ruling recognizes any health care provider accepted by the employer's
group health (or equivalent) plan and adds clinical social workers to the extent authorized under State
law to independently diagnose and treat serious health conditions without supervision. Physician
assistants are not specifically included, as they are ordinarily limited to practicing under a doctor's
supervision, but any services or treatments they furnish under the supervision of a doctor, and any
services recognized by the employer's health plan furnished on referral and under continuing
supervision of a health care provider as defined, would qualify as medical treatment for purposes of
FMLA.
____________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
________________________________________________ ____ ____________________________________
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
t
h:____
___
___
_
____
___
___
_
____
___
___
_
____
___
___
_
_
Describe care
y
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.
City of Allentown, 435 W. Hamilton Street, Human Resources, Room 233, Allentown, PA 18101
Fax: (610) 437-7675, Phone: (610) 437-7523
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
m
e
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?
___
No
___Yes.
Will the patient need to
have treat
m
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
5
__________________________________________________________________________________________
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
d
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? __
No
__
Yes.
Estim
a
te the
hours the pati
ent needs care on an inter
m
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
h
e medical co
ndition, estimate the frequency
of
flare-ups and the duration
o
f
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
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MEMORAN DUM (City of Allentown)

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Completed 12 January 2021

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