____ _ ___ _
_
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__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
____________________________________________________________________________ ____________________________________________ __________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________
____________________________________________________________________________________________________________________________________________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ ____________ _____________ ____________ __________ ____________ ____________ ____________ __________ _____________ ____________ ____________ __________ ____________ ____________ ____________ ___________ ____________ ____________ ____________ __________ ____________ ____________ _____________ __________ ____________ ____________ ____________ __________ _________
If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave (only checked blanks apply):
____ Contact _____________________________________ at ___________________________ to make arrangements to continue to make your share
of the premium payments on your health insurance t o maintain health benefits while you are on leave. You have a minimum 30-day (or, indicate
longer period, if applicable) grace period in which to
make premium payments. If payment is
not made timely, your group health insurance may be
cancelled, provide
d we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your
share of the premiums during FMLA leave, and recover these payments from you upon your return to work.
____ You will be required to use your available paid ______ sick, _______ vacation, and/or ________other leave during y
our FMLA absence. This
means that you will receive your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave
entitlement.
____ Due to your status within the company, you are considered a “key
employee” as define
d in the FMLA. As a “key employee,” restoration to
employment may
be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us.
We ___have/____ have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous
economic harm to us.
____ While on leav
e you will be required to furnish us with periodic reports of your status and intent to return to work every __________
____________.
(Indicate interval of periodic reports, as appropriate for the particular leave situation).
If the circumstances of your leave change, and you are able to return to wo
rk earlier than the date indicated on the this form, you will be required
to notify us
at least two workdays prior to the date you intend to report for work.
If your leave does qualify as
FMLA leave you will have the following rights while on FMLA leave:
• You have a right under the FMLA for up to 12 week
s of unpaid leave in a 12-month period calculated as:
_____ the calendar year (January – December).
_____ a fixed leave year based on _______________________________________________________________________________________.
_____ the 12-month period measured forward from the date
of your first FMLA leave usage.
_____ a “rolling” 12-month period measured backward from the date of any FMLA leave usage.
• You have a right
under the FMLA for up to 26 weeks of unpaid leave in a single 1
2-month period to care for a covered servicemember with a serious
injury or illness. This single 12-month period commenced on ________________________________________________________________________.
• Your health benef
its must be maintained during any period of unpaid leave under the same conditions as if you continued to work.
• You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from
FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not
have return rights under FMLA.)
• If you do not return to work following FMLA leave for a reason other than: 1) the continuation, recurrence, or onset of a serious health condition which
would entitle you to FMLA leave; 2) the continuation, recurrence, or onset of a covered servicemember’s serious injury or illness which wo
uld entitle
you to FMLA leave; or 3) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums
paid on your behalf during your FMLA leave.
• If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA leave entitlement, you have the right to have
____ sick, ____vacation, and/or ___ other leave run concurrently with your unpaid le
ave entitlement, provided you meet any applicable requirements
of the leave policy. Applicable conditions related to the substitution of paid leave are referenced or set forth below. If you do not meet the requirements
for taking paid leave, you remain entitled to take unpaid FMLA leave.
____For
a copy of conditions applicable to sick/vacation/other leave usage please refer to ____________ available at: ___________________________.
____Applicable conditions for use of paid leave:_____________________________________________
______________________________________
Once we obtain th
e information from you as specified above, we will inform you, within 5 business days, whether your leave will be designated as
FMLA leave and count towards your FMLA leave entitlement. If you have any questions, please do not hesitate to
contact:
_______________________________________________at ______________________________________.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
It is mandatory for employers to provide employees with notice of their eligibility for FMLA protection and their rights and responsibilities. 29 U.S.C. § 2617; 29
C.F.R. § 825.300(b), (c). It is mandatory for em
ployers to retain a copy of this disclosure in their recor
ds for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it
will take an average of 10 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden
estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division,
U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WA
GE
AND HOUR DIVISION.
Page 2 Form WH-381 Revised February 2013