Fill - Free fillable Medical Leave Faculty For Family Member Packet (Southern West Virginia Community and Technical College) PDF form

IMPORTANT NOTICE TO

FACULTY

REQUESTING MEDICAL LEAVE

DUE TO FAMILY MEMBER’S

SERIOUS HEALTH CONDITION

Southern West Virginia Community and Technical College

NAME: Date:

This notice will serve as a reminder that faculty employees who are unable to work

for a period of thirty (30) calendar days will be taken off the institution’s

payroll at the end of the 30-day period (See SCP-2006 § 6.5.4). This policy also

requires employees who have been absent longer than two consecutive work weeks,

due to medical reasons for themselves or a family member, complete a request for

medical leave and the supporting physician’s statement. Failure to comply with

policy may result in the employee being removed from the payroll.

This period of medical leave will count toward entitlement of the Family and

Medical Leave Act of 1993 (FMLA) as applicable, which provides up to 12 weeks

job-protected leave to eligible employees for certain family and medical reasons.

This period of medical leave also counts toward entitlement provided by the WV

Parental Leave Act, as applicable.

Please refer to SCP-2006 for additional information regarding Employee Leave.

Contact Human Resources:

Doug Kennedy

304.896.7408 or doug.kennedy@southernwv.edu

Susan Ross

304.896.7445 or susan.ross@southernwv.edu

REQUEST FOR

MEDICAL LEAVE OF ABSENCE

MILITARY FAMILY LEAVE

Name: Employee ID No:

Title: Dept: _____

I hereby request a leave of absence as follows:

Beginning Date: ___

Ending Date: ___

Purpose of Leave:

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

” Your own serious health condition

” You are needed to care for your spouse, child, or parent due to his/her serious health condition

” Qualifying exigency arising out of the fact that your spouse, son or daughter, or parent is on active duty or call to

active duty status in support of a contingency operation as a member of the National Guard or Reserves

” You are the spouse, son or daughter, parent, or next of kin of a covered servicemember with a serious injury or illness

I understand that while on an approved Leave of Absence, I am required to continue to pay my respective proportionate share of

health/life/hospitalization/drug insurance coverage premium cost. I further understand that if the approved leave continues after 12

consecutive months, I may be required to pay the full cost of coverage (employee and employer’s share).

I further understand that prior to my return to work, I am required to submit to my employer the Return to Work Authorization

/Medical Release form from the treating licensed physician (except in the case of Military Family Leave due to qualifying exigency).

I further understand that the extent of this leave will count toward entitlement of the Family and Medical Leave Act (FMLA), which

provides up to 12 weeks job-protected leave to eligible employees for certain family and medical reasons and up to 26 weeks job-

protected leave to eligible employees to care for a covered servicemember under the Military Family Leave entitlement. See the

attached publication by the U.S. Department of Labor entitled “Employee Rights and Responsibilities Under the Family and Medical

Leave Act” (WHD Publication 1420).

I further understand that any extension of this leave must be requested in writing by completing a new Request for Medical Leave

of Absence or Military Family Leave and provide a new Certification, and be submitted for the President’s approval prior to the

expiration of this approved leave.

I understand that approval of this Request does not guarantee payment of wages, leave or other compensation and that

all policies, rules, and laws in regard to leave payment apply.

**IMPORTANT**

This request form MUST be accompanied by either a Certification of Health Care Provider (DOL Form WH-380-E or WH-380-F),

Certification of Qualifying Exigency (DOL Form WH-384), or a

Certification for Serious Injury or Illness of Covered Servicemember (Form WH-385)

Employee’s Signature Date

I recommend approval of this leave __Yes __No

Supervisor’s Signature Date

I recommend approval of this leave __Yes __No

Unit Administrator’s Signature Date

I recommend approval of this leave __Yes __No

Human Resources Administrator’s Signature Date

“ Approved “ Denied

Revised 3/16/2010 President or Designee’s Signature Date

RESERVED

FOR

HUMAN

RESOURCES

DEPARTMENT

USE

ONLY

DO NOT WRITE IN THIS BOX

I. Date leave commenced _____________ Expected end date _____________

II. Non-Faculty Employees Only:

1. Verification of Leave Balances as of _______________________ (Date)

Annual Leave _________ days

Sick Leave _________ days

2. Exhaustion of all sick/annual leave as of _______________________

(Date & Time)

3. Date Catastrophic Leave Request Form Sent ____________________________

(30 days prior to expiration of leave)

4. Applied for Catastrophic Leave? “ YES “ NO “ N/A

III. Date notification letter sent: _________________

IV. Verification of receipt of monthly physician’s statement:

Month

Date Rec’d in HR Month Date Rec’d in HR

(List below) (List Below)

_______ _____________ _______ ____________

V. Verification of receipt of monthly insurance premiums:

Month

Date Rec’d in HR Month Date Rec’d in HR

(List below) (List Below)

_______ _____________ _______ ____________

VI. Date of Actual Return to Work/Duty: _________________________

Date extension of leave requested: __________________________

Page 1 of 1

FACULTY ABSENCE REQUEST/REPORT

Name _______________________________________ Campus________________________________

Date of Absence: _________________________________________________________________________

If less than full day, also indicate time.

Section A

Planned Absence

1. Reason for Absence_________________________________________________________________

_________________________________________________________________________________

2. Class(es) will be covered by:

_____ Colleague ______________________ _____ Guest Lecturer ___________________

_____ Division Chair/Campus Director _____ Special Class Assignment

_____ Make-up time

3. Duties to be missed:

_____ Office Hours _____ Registration _____ Advising

_____ Scheduled Meeting (s) _____ Commencement _____ Other

Section B

Unplanned Absence

1. Reason for Absence ________________________________________________________________

_________________________________________________________________________________

2. Was Division Chairperson notified prior to Absence? _____ Yes _____ No

___________________________________________________

Employee Signature Date

___________________________________________________

Supervisor Signature Date

Revised 3/16/2010

RETURN TO WORK AUTHORIZATION

MEDICAL RELEASE FORM

PHYSICIAN - COMPLETE IN ENTIRETY:

Patient’s Name:

I hereby certify that the above-named employee has been under my professional care for:

(Diagnosis)

Illness commenced:

(Date)

Employee is able to return to work on:

(Date)

Describe the functional limitations/restrictions, if any, caused by this condition:

(Functional limitations listed may require an analysis of employee’s Position Information Questionnaire (PIQ) for ADA

accommodation)

Duration of limitations/restrictions, if any:

” Permanent ” Temporary

If temporary, indicate time period:

Signature of Physician

Printed Name

Address of Physician

Telephone Number of Physician

Revised 3/16/2010

____________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

________________________________________________ ________________________________________

Certification of Health Care Provider for

U.S. Department of Labor

Family Member’s Serious Health Condition

Employment Standards Administration

(Family and Medical Leave Act)

Wage and Hour Division

OMB Control Number: 1215-0181

Expires: 12/31/2011

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.

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 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 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 birth:_____________________________________________

Describe care you 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 January 2009

Southern WV Community & Technical College, P.O. Box 2900, Mount Gay, WV 25637 (304) 897-7416

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. 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, hospice, or residential medical 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 treatment visits at least twice per year due to the condition? ___No ____ Yes

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

____ No ____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. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such

medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of

specialized equipment):

Page 2 CONTINUED ON NEXT PAGE Form WH-380-F Revised January 2009

__________________________________________________________________________________________

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.

Estimate the beginning and ending dates for the period of incapacity: ___________________________________

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

Explain the care 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.

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for

each appointment, including any recovery period:

Explain the care 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.

Estimate the hours the patient needs care on an intermittent basis, if any:

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

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

Page 3 CONTINUED ON NEXT PAGE Form WH-380-F Revised January 2009

___________________________________________________________________________________________

______________________________________________ ____________________________________________

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

activities? ____No ____Yes.

Based upon the patient’s medical history and your knowledge of the 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

Does the patient need care during these flare-ups? ____ No ____ Yes.

Explain the care 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 January 2009

EMPLOYEE RIGHTS AND RESPONSIBILITIES

UNDER THE FAMILY AND MEDICAL LEAVE ACT

Basic Leave Entitlement

FMLA requires covered employers to provide up to 12 weeks of unpaid,

job-protected leave to eligible employees for the following reasons:

• for incapacity due to pregnancy, prenatal medical care or child birth;

• to care for the employee’s child after birth, or placement for adoption

or foster care;

• to care for the employee’s spouse, son, daughter or parent, who has

a serious health condition; or

• for a serious health condition that makes the employee unable to

perform the employee’s job.

Military Family Leave Entitlements

Eligible employees whose spouse, son, daughter or parent is on covered

active duty or call to covered active duty status may use their 12-week

leave entitlement to address certain qualifying exigencies. Qualifying

exigencies may include attending certain military events, arranging for

alternative childcare, addressing certain nancial and legal arrangements,

attending certain counseling sessions, and attending post-deployment

reintegration briengs.

FMLA also includes a special leave entitlement that permits eligible

employees to take up to 26 weeks of leave to care for a covered service-

member during a single 12-month period. A covered servicemember is:

(1) a current member of the Armed Forces, including a member of the

National Guard or Reserves, who is undergoing medical treatment,

recuperation or therapy, is otherwise in outpatient status, or is otherwise

on the temporary disability retired list, for a serious injury or illness*;

or (2) a veteran who was discharged or released under conditions other

than dishonorable at any time during the ve-year period prior to the

rst date the eligible employee takes FMLA leave to care for the covered

veteran, and who is undergoing medical treatment, recuperation, or

therapy for a serious injury or illness.*

*The FMLA denitions of “serious injury or illness” for

current servicemembers and veterans are distinct from

the FMLA definition of “serious health condition”.

Benets and Protections

During FMLA leave, the employer must maintain the employee’s health

coverage under any “group health plan” on the same terms as if the

employee had continued to work. Upon return from FMLA leave, most

employees must be restored to their original or equivalent positions

with equivalent pay, benets, and other employment terms.

Use of FMLA leave cannot result in the loss of any employment benet

that accrued prior to the start of an employee’s leave.

Eligibility Requirements

Employees are eligible if they have worked for a covered employer for at

least 12 months, have 1,250 hours of service in the previous 12 months*,

and if at least 50 employees are employed by the employer within 75 miles.

*Special hours of service eligibility requirements apply to

airline ight crew employees.

Denition of Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical

or mental condition that involves either an overnight stay in a medical

care facility, or continuing treatment by a health care provider for a

condition that either prevents the employee from performing the functions

of the employee’s job, or prevents the qualied family member from

participating in school or other daily activities.

Subject to certain conditions, the continuing treatment requirement may

be met by a period of incapacity of more than 3 consecutive calendar days

combined with at least two visits to a health care provider or one visit and

a regimen of continuing treatment, or incapacity due to pregnancy, or

incapacity due to a chronic condition. Other conditions may meet the

denition of continuing treatment.

Use of Leave

An employee does not need to use this leave entitlement in one block.

Leave can be taken intermittently or on a reduced leave schedule when

medically necessary. Employees must make reasonable efforts to schedule

leave for planned medical treatment so as not to unduly disrupt the

employer’s operations. Leave due to qualifying exigencies may also be

taken on an intermittent basis.

Substitution of Paid Leave for Unpaid Leave

Employees may choose or employers may require use of accrued paid

leave while taking FMLA leave. In order to use paid leave for FMLA

leave, employees must comply with the employer’s normal paid leave

policies.

Employee Responsibilities

Employees must provide 30 days advance notice of the need to take

FMLA leave when the need is foreseeable. When 30 days notice is not

possible, the employee must provide notice as soon as practicable and

generally must comply with an employer’s normal call-in procedures.

Employees must provide sufcient information for the employer to determine

if the leave may qualify for FMLA protection and the anticipated timing

and duration of the leave. Sufcient information may include that the

employee is unable to perform job functions, the family member is unable

to perform daily activities, the need for hospitalization or continuing

treatment by a health care provider, or circumstances supporting the need

for military family leave. Employees also must inform the employer if

the requested leave is for a reason for which FMLA leave was previously

taken or certied. Employees also may be required to provide a certication

and periodic recertication supporting the need for leave.

Employer Responsibilities

Covered employers must inform employees requesting leave whether

they are eligible under FMLA. If they are, the notice must specify any

additional information required as well as the employees’ rights and

responsibilities. If they are not eligible, the employer must provide a

reason for the ineligibility.

Covered employers must inform employees if leave will be designated

as FMLA-protected and the amount of leave counted against the employee’s

leave entitlement. If the employer determines that the leave is not

FMLA-protected, the employer must notify the employee.

Unlawful Acts by Employers

FMLA makes it unlawful for any employer to:

• interfere with, restrain, or deny the exercise of any right provided

under FMLA; and

• discharge or discriminate against any person for opposing any practice

made unlawful by FMLA or for involvement in any proceeding under

or relating to FMLA.

Enforcement

An employee may le a complaint with the U.S. Department of Labor

or may bring a private lawsuit against an employer.

FMLA does not affect any Federal or State law prohibiting discrimination,

or supersede any State or local law or collective bargaining agreement

which provides greater family or medical leave rights.

FMLA section 109 (29 U.S.C. § 2619) requires FMLA

covered employers to post the text of this notice. Regulation

29 C.F.R. § 825.300(a) may require additional disclosures.

For additional information:

1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627

WWW.WAGEHOUR.DOL.GOV

U.S. Department of Labor Wage and Hour Division

WHD Publication 1420 · Revised February 2013

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