IMPORTANT NOTICE
REGARDING YOUR REQUEST
FOR MEDICAL LEAVE
DUE TO EMPLOYEE’S
SERIOUS HEALTH CONDITION
Southern West Virginia Community and Technical College
NAME: Date:
This will serve as official notification that your medical leave counts 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.
Policy SCP-2006 Employee Leave 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.
Once your leave is approved, you will remain on the institution’s payroll until the
expiration of your sick and annual leave. Prior to this expiration date you may
wish to request Catastrophic Leave, wherein other employees may donate leave
time to you so as not to disrupt your receipt of income.
If your disability is continuous for six (6) months, you will need to make a claim for
benefits with the group long-term disability plan
(if you are a participant in this plan).
You should also file a claim for disability benefits with the Social Security
Administration and your group retirement plan.
Please refer to SCP-2006 for additional information regarding Employee Leave.
Contact Human Resources:
Doug Kennedy
304.896.7408 or doug.kennedy@southernwv.edu
or
Susan Ross
304.896.7445 or susan.ross@southernwv.edu
REQUEST FOR
MEDICAL LEAVE OF ABSENCE
OR
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
RESERVED
FOR
FOR
HUMAN
HUMAN
RESOURCES
RESOURCES
DEPARTMENT
DEPARTMENT
USE
USE
ONLY
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: _________________________
OR
Date extension of leave requested: __________________________
Employee Name
Date Submitted
Request for Leave
Other:
Date(s):
Time(s):
Number of Hours to
be Charged to Leave:
Request to Attend Meeting/Semina
r
I. Name of Meeting or Seminar
II. Date/s
Annual Leave Sick Leave
LEAVE
REQUEST
III. Time
IV. Estimated Length of Meeting
V. Meeting Location
FMLA Notice
Overtime and Compensatory Time
ATTENTION SUPERVISOR
Please hold the Original copy until Employee Signature Date
the end of the month. Attach the
original to the employee's Time
Card and forward to Human
Resources. Make one copy for
Approved by Supervisor Date
your records and one copy to
return to the employee. Revised November 1, 2007
For requests and approvals for Compensatory Time and to work Overtime, please refer to SCP-2575 and SCP-
2575.A.
The extent of your leave used for medical reasons counts 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.
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
Employee’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 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.
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. 20 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.
Please be sure to sign the form on the last page.
Provider’s name and business address: ___________________________________________________________
Type of practice / Medical specialty: ____________________________________________________________
Telephone: (________)____________________________ Fax:(_________)_
____________________________
Page 1 CONTINUED ON NEXT PAGE Form WH-380-E Revised January 2009
Southern WV Community & Technical College, PO Box 2900 Mount Gay, WV 25637 (304) 896-7416
________________________________________________________________________________________
________________________________________________________________________________________
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________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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________________________________________________________________________________________
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, hospice, or residential medical care facility?
___No
___Yes. If so, dates of admission:
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year 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 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. Use the information provided by the employer in Section I to answer this question. If the employer fails to
provide a list of the employee’s essential functions or a job description, 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 employee 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 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-E
Revised January 2009
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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, estimate 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 medically 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 employee needs, if any:
__________ hour(s) per day; __________ days per week from _____________ 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 absent from work during the flare-ups?
____
No
____
Yes
. If so, explain:
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
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL
ANSWER.
Page 3 CONTINUED ON NEXT PAGE
Form WH-380-E
Revised January 2009
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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-E
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
employers 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 employers 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 employers 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