Fill - Free fillable Military Service Member Packet (Southern West Virginia Community and Technical College) PDF form

IMPORTANT NOTICE

REGARDING YOUR REQUEST

FOR MILITARY FAMILY LEAVE

(COVERED SERVICEMEMBER)

Southern West Virginia Community and Technical College

NAME: Date:

This will serve as official notification that this period of medical leave counts

toward entitlement of Military Family Leave under the Family and Medical Leave

Act (FMLA), which provides up to 26 weeks job-protected leave during a single 12-

month period for eligible employees to care for a covered servicemember who has

a serious injury or illness incurred in the line of duty on active duty.

SCP-2006 Employee Leave policy 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.

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

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 for Serious Injury or

Illness of Covered Servicemember - -

for Military Family Leave (Family and

Medical Leave Act)

U.S. Department of Labor

Employment Standards Administration

Wage and Hour Division

____________________________________________________________________________________________________________________________________________________________________________________________________________

OMB Control Number: 1215-0181

Expires: 12/31/2011

Notice to the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act

(FMLA) provides that an employer may require an employee seeking FMLA leave due to a serious injury or illness

of a covered servicemember to submit a certification providing sufficient facts to support the request for leave.

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. § 825.310. Employers must generally

maintain records and documents relating to medical certifications, recertifications, or medical histories of

employees or 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.

SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom

the Employee Is Requesting Leave INSTRUCTIONS to the EMPLOYEE or COVERED

SERVICEMEMBER: Please complete Section I before having Section II completed. The FMLA permits an

employer to require that an employee submit a timely, complete, and sufficient certification to support a request for

FMLA leave due to a serious injury or illness of a covered servicemember. If requested by the employer, your

response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. §§ 2613, 2614(c)(3).

Failure to do so may result in a denial of an employee’s FMLA request. 29 C.F.R. § 825.310(f). The employer

must give an employee at least 15 calendar days to return this form to the employer.

SECTION II: For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH

CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of

Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care

provider; or (3) a DOD non-network TRICARE authorized private health care provider INSTRUCTIONS

to the HEALTH CARE PROVIDER: The employee listed on Page 2 has requested leave under the FMLA to

care for a family member who is a member of the Regular Armed Forces, the National Guard, or the 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. For purposes of FMLA leave, a serious injury or

illness is one that was incurred in the line of duty on active duty that may render the servicemember medically unfit

to perform the duties of his or her office, grade, rank, or rating.

A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember’s

serious injury or illness includes written documentation confirming that the covered servicemember’s injury or

illness was incurred in the line of duty on active duty and that the covered servicemember is undergoing treatment

for such injury or illness by a health care provider listed above. 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.

Page 1 CONTINUED ON NEXT PAGE Form WH-385 January 2009

Certification for Serious Injury or Illness

of Covered Servicemember - - for

Military Family Leave (Family and

Medical Leave Act)

U.S. Department of Labor

Employment Standards Administration

Wage and Hour Division

SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom

the Employee Is Requesting Leave: (This section must be completed first before any of the below sections can be

completed by a health care provider.)

Part A: EMPLOYEE INFORMATION

Name and Address of Employer (this is the employer of the employee requesting leave to care for covered

servicemember):

____________________________________________________________________________________________

Name of Employee Requesting Leave to Care for Covered Servicemember:

____________________________________________________________________________________________

First Middle Last

Name of Covered Servicemember (for whom employee is requesting leave to care):

____________________________________________________________________________________________

First Middle Last

Relationship of Employee to Covered Servicemember Requesting Leave to Care:

⁪ Spouse ⁪ Parent ⁪ Son ⁪ Daughter ⁪ Next of Kin

Part B: COVERED SERVICEMEMBER INFORMATION

(1) Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or

Reserves? ___Yes ____No

If yes, please provide the covered servicemember’s military branch, rank and unit currently assigned to:

_______________________________________________________________________________________

Is the covered servicemember assigned to a military medical treatment facility as an outpatient or to a unit

established for the purpose of providing command and control of members of the Armed Forces receiving

medical care as outpatients (such as a medical hold or warrior transition unit)? ___

Yes ___No If yes, please

provide the name of the medical treatment facility or unit:

_________________________________________

(2) Is the Covered Servicemember on the Temporary Disability Retired List (TDRL)? ____Yes ____No

Part C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER

Describe the Care to Be Provided to the Covered Servicemember and an Estimate of the Leave Needed to Provide

the Care:

____________________________________________________________________________________________

Page 2 CONTINUED ON NEXT PAGE Form WH-385 January 2009

Southern WV Community & Technical College, P.O. Box 2900, Mount Gay, WV 25637 Telephone: (304) 896-7416

SECTION II: For Completion by a United States Department of Defense (“DOD”) Health Care Provider or

a Health Care Provider who is either: (1) a United States Department of Veterans Affairs (“VA”) health

care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-

network TRICARE authorized private health care provider. If you are unable to make certain of the

military-related determinations contained below in Part B, you are permitted to rely upon determinations

from an authorized DOD representative (such as a DOD recovery care coordinator). (Please ensure that

Section I above has been completed before completing this section.) Please be sure to sign the form on the last

page.

Part A: HEALTH CARE PROVIDER INFORMATION

Health Care Provider’s Name and Business Address:

____________________________________________________________________________________________

Type of Practice/Medical Specialty: _______________________________________________________________

Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD

TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized

private health care provider: _____________________________________________________________________

Telephone: ( ) _____________ Fax: ( ) ______________ Email: ___________________________________

PART B: MEDICAL STATUS

(1) Covered Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):

⁪ (VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently

endangered. Family members are requested at bedside immediately. (Please note this is an internal DOD

casualty assistance designation used by DOD healthcare providers.)

⁪ (SI) Seriously Ill/Injured – Illness/injury is of such severity that there is cause for immediate concern,

but there is no imminent danger to life. Family members are requested at bedside. (Please note this is an

internal DOD casualty assistance designation used by DOD healthcare providers.)

⁪ OTHER Ill/Injured – a serious injury or illness that may render the servicemember medically unfit to

perform the duties of the member’s office, grade, rank, or rating.

⁪ NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take

leave to care for a covered family member with a “serious health condition” under § 825.113 of the FMLA.

If such leave is requested, you may be required to complete DOL FORM WH-380 or an employer-provided

form seeking the same information.)

(2) Was the condition for which the Covered Service member is being treated incurred in line of duty on active

duty in the armed forces? ____ Yes

____ No

(3) Approximate date condition commenced: _______________________________________________

(4) Probable duration of condition and/or need for care: ______________________________________

(5) Is the covered servicemember undergoing medical treatment, recuperation, or therapy? ____Yes ___No. If

yes, please describe medical treatment, recuperation or therapy:

_________________________________________________________________________________________

Page 3 CONTINUED ON NEXT PAGE Form WH-385 January 2009

PART C: COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER

(1) Will the covered servicemember need care for a single continuous period of time, including any time for

treatment and recovery? ___ Yes ___ No

If yes, estimate the beginning and ending dates for this period of time: ________________________________

(2) Will the covered servicemember require periodic follow-up treatment appointments?

___ Yes ___ No If yes, estimate the treatment schedule: __________________________________________

(3) Is there a medical necessity for the covered servicemember to have periodic care for these follow-up treatment

appointments? ____Yes _____No

(4) Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled

follow-up treatment appointments (e.g., episodic flare-ups of medical condition)? ____Yes ____No If yes,

please estimate the frequency and duration of the periodic care:

_________________________________________________________________________________________

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, in accordance with 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 AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM

TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE PATIENT.

Page 4 Form WH-385 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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