Fillable STATE OF ARIZONA Families First Coronavirus Response Act, (Arizona)

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STATE OF ARIZONA Families First Coronavirus Response Act, (Arizona)

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Families First Coronavirus Response Act
1Notice of FMLA Eligibility and Rights and Responsibilities
Revised March 30, 2020
STATE OF ARIZONA
Families First Coronavirus Response Act, Effective 04/01/20 - 12/31/20
Notice of Eligibility and Rights and Responsibilities
(Emergency Family and Medical Leave Expansion Act)
This form should be provided within five business days of an employee notifying the employer of
the need for Emergency FMLA Expansion Act Leave under the Families First Coronavirus
Response Act. Employees seeking Family and Medical Leave Act (FMLA) leave for any other
reason should be provided the State’s FMLA form ASPS/HRD - FA6.03 5/2018. Employees
seeking sick leave for any other reason should consult with their supervisor or Human
Resources representative. Part B provides employees with information regarding their rights
and responsibilities for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).
P
art A – NOTICE OF ELIGIBILITY
T
O: ________________________________________
Employee
FR
OM: ________________________________________
Employer Representative
D
ATE: _______________________________________
O
n _____________________, you informed us that you needed leave beginning on
_______________________ because:
You need leave to care for your child/ren under 18 years of age because the school or place of
care has been closed, or the child care provider of your child/ren is unavailable, due to a public
health emergency relating to the Coronavirus (COVID-19).
This Notice is to inform you that you:
_____ Are eligible for Emergency FMLA Expansion Act leave (See Part B below for Rights and
Responsibilities)
_____ Are not eligible for Emergency FMLA Expansion Act leave, because (only one reason
need be checked, although you may not be eligible for other reasons):
days toward this requirement.
You have not met the Emergency FMLA Expansion Act’s 30-day length of service
As of the first date of requested leave, you will have worked approximately
_____
____
You have exhausted your 12-week FMLA leave entitlement in the applicable 12-
month period.
_____
Please provide this information by: . If sufficient information is
not provided in a timely manner, your leave may be denied.
If your leave does qualify as Emergency FMLA Expansion Act leave you will have the
following responsibilities while on FMLA leave (only checked blanks apply):
to us. We
While on leave you may be required to furnish us with periodic reports of your status and
intent to return to work.
Families First Coronavirus Response Act
2Notice of FMLA Eligibility and Rights and Responsibilities
Revised March 30, 2020
have not determined that restoring you to employment at the
conclusion of FMLA leave will cause substantial and grievous economic harm to us.
have/
Due to your status within the agency, you are considered a “key employee” as defined 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
You work in a position that has been designated as a health care provider or
emergency responder, and as such, you are excluded from this provision of the FMLA.
If you have any questions, contact
or review the other information provided with this form.
PART B - RIGHTS AND RESPONSIBILITIES FOR TAKING EMERGENCY FMLA
EXPANSION ACT LEAVE
As explained in Part A, you meet the eligibility requirements for taking Emergency FMLA
Expansion Act leave and still have FMLA leave available in the applicable 12-month period.
No additional information requested.
Other information is needed:
____________________________________________________________________________
_____
_______________________________________________
____
____
____________________________________________________________________________
____
______________________
___ ____
____
Families First Coronavirus Response Act
3Notice of FMLA Eligibility and Rights and Responsibilities
Revised March 30, 2020
If the circumstances of your leave change, and you are able to return to work earlier than
the date indicated on this form, you will be required to notify us at least two work days
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 weeks of unpaid leave in a 12-month period
calculated as 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 12-month
period to care for a covered servicemember with a serious injury or illness. This single 12-
month period, if applicable, commenced on: _____________________________________
• Your health benefits must be maintained during any period of this 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.
The following provisions of the Emergency FMLA Expansion Act apply to this FMLA
leave, if approved:
● The first 10 days are unpaid; however, you may use available Emergency Paid Sick
Leave, Sick Leave or Annual Leave during this time, providing you meet the
requirements under the applicable State Personnel System Rules.
● Leave after the first 10 days is paid leave at 2/3 of your regular rate of pay for the
number of hours you would normally be scheduled to work, capped at $200 per day and
$10,000 in total. For more information on how this is calculated, including the amount
you would receive if you work a varying schedule, you may contact
____________________________ at _________________________.
● You may supplement this 2/3 pay with your own available sick leave and/or annual leave
balance(s) to bring your pay to 100% during this leave. If you have exhausted your
accrued sick and annual leave, you may request paid administrative leave during this
time.
● Leave under this provision can be taken intermittently.
Families First Coronavirus Response Act
4Notice of FMLA Eligibility and Rights and Responsibilities
Revised March 30, 2020
All other provisions of the FMLA remain intact, so for example, if an employee has already used
6 weeks of FMLA leave during the past 12 months, he/she is eligible for just 6 weeks of FMLA
at this time. If an employee has exhausted 12 weeks of this leave, he/she is not eligible for any
more FMLA leave until the 12-month period has expired.
Once we obtain the 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: _________________________.
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STATE OF ARIZONA Families First Coronavirus Response Act, (Arizona)

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Completed 12 August 2020

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