FMLA FORM

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Local 338 RWDSU & Affiliated Benefit Funds FAMILY AND MEDICAL LEAVE ACT (FMLA) LEAVE OF ABSENCE REQUEST/APPROVAL

REQUEST

(to be filled out by employee)

Employee Name (please print)(*)

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Position(*)

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Purpose(*)

Work related serious health condition of employee

Pregnancy Disability (excluding newborn child care)

Other Serious health condition of employee

Care of a child/spouse/parent with serious health risk

Newborn/adoption/foster child care

Military Service

All other

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Describe Below

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Requested Period of Absence: Begining Date (*)

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Continuing through:(*)

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Has this Request been Approved?

Yes

No

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From

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To

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Has this Request been Renewed?

Yes

No

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From

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To

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Employee:(*)

Is eligible for FMLA leave and employee's leave qualifies as FMLA leave (see below for Rights and Responsibilities).

Is eligible, BUT must provide more information in order to determine whether absence qualifies as FMLA leave. If employee fails to provide. complete and sufficient certification in a timely manner or fails to cure any deficiency after being notified of the deficiency, the employer may deny the request for FMLA leave.

Is NOT eligible for FMLA leave or leave does not qualify.

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Length of Leave:

The 12-month period in which the employee can use the 12 weeks of FMLA entitlement will be measured backward from the date an employee uses any FMLA leave.

Care for a covered military service member with a serious injury or illness is limited to a total of 26 workweeks of leave during a single 12-month period. The 12-month period will be measured forward from the beginning date of an employee's first FMLA leave to care for the covered military service member.

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Within 15 days, employee should provide:

Certification of need for absence by a health care provider

Certification of qualifying exigency due to military service member's call to duty.

Sufficient documentation to establish required relationship between you and your family member.

Other information:

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Other Information

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Employee:

has not met the FMLA's 12-month length of service requirement. As of date of requested leave, employee will have worked approximately "x" months toward this requirement.

has not met the FMLA's 1,250-hours-worked requirement.

has exhausted FMLA leave entitlement.

has requested leave for a reason not covered by the FMLA.

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Number of Months

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Employee Rights and Responsibilities

(office use only)

Compensation

Unused vacation, sick, and personal day entitlement must be taken at the beginning of the leave. It D will D will not be counted as part of leave.

If applicable to the absence, other paid time off benefits as described below must be taken and will not be counted as part of the

No compensation (other than described below) will be paid during the leave of absence

Other:

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Other Information

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Service Credit

If return is timely and conditions are met, service credit will be calculated as if no absence had occurred.

No service credit will be accumulated during the term of the leave.

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Accruals

Paid time off benefits (i.e., vacation) will NOT accrue or accumulate during any unpaid portion of the leave.

Paid time off benefits will accrue during the leave as follows:

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Paid time off benefits

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Group Insurance

Employer will provide health, but not dental, coverage to participating employee during leave of absence .

Coverage will cease on ( ) except that continuation is allowed under COBRA regulations if applicable to the plan.

Coverage will continue during the leave providing employee pays a premium of ( ) as follows.

Other

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Other Information

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Provide Date(*)

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Provide information regarding coverage plan.

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Reinstatement

If return is timely and conditions are met, reinstatement will be made to the same or equivalent position (assuming no layoff would have occurred)

Due to employee's status within the company, employee is 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 to employer. We have/have not (circle one) determined that restoring the employee to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to employer.

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Health Care Certification

As noted above, certification or need for absence by a health care provider is required prior to commencement of the leave.

Certifications by a health care provider regarding continuing need for absence are required every ( ) days during the term of the leave.

A health care provider's fitness-far-duty certification and release is required upon return to active employment.

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Number of Days

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Forfeiture

If employee fails to meet any required conditions of this leave, he/she may be considered to have voluntarily resigned his/her employment.

If employee accepts employment elsewhere while on leave, voluntary resignation may occur as of the date other employment is accepted.

If employee fails to notify or return upon expiration of the leave, he/she may be considered to have voluntarily resigned his/her employment.

Any employee who fraudulently obtains a leave of absence is subject to immediate discharge.

Should employee be otherwise subject to layoff had he/she been actively employed, he/she will be similarly subject to layoff while on leave.

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Renewal

Renewal or extension of this leave may be considered if proper request is made not later than ( ) days prior to its expiration.

Renewal or extension of this leave is NOT available.

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Number of Days

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If additional comments are necessary please select "yes" and type in the appropriate box.

Yes

No

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Additional Comments

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Granting this leave of absence does not create a contract of employment or reemployment for an specified period of time: employment is for no fixed tern and may be terminated with or without cause or notice, at any time, at the option of the employer or employee. The terms and conditions of this leave may be subject to change.

Acknowledgment

Approved By(*)

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Date

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Employee Signature(*)

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Date

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CAPTCHA(*)

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