Family Medical Leave Act

The Family and Medical Leave Act of 1993 (FMLA) gives certain job protections to employees when balancing work responsibilities with the demands of personal illness or injury or in caring for family members. If you or your employee need to be out for an extended period of time, please contact Employment Services at 974-2575.

FMLA provides an entitlement of up to 12 weeks of job-protected, unpaid leave during any 12-month period to eligible, covered employees for the following reasons:

1. birth and care of the eligible employee's child, or placement for adoption or foster care of a child with the employee;
2. care of an immediate family member (spouse, child, parent) who has a serious health condition; or
3. care of the employee's own serious health condition.

It also requires that employee's group health benefits be maintained during the leave.

More information about FMLA can be found on the United States Department of Labor website.

Forms:

• FMLA Request Form:  This form is to be completed by the employee who would like to request FMLA leave.
• Requirements for Employees Requesting FMLA:  This form outlines FMLA actions for the employee applying for FMLA.
• Certification from Health Care Provider:  This form is to be completed by the physician for the employee going out for a serious health condition.
• Certification for Family Member:  This form is to be completed by the physician for the employee whose family member has a serious health condition.
• Maternity Checklist Form:  This form is to be completed prior to the 24th week of pregnancy by the employee going out on maternity leave.
• Birth of Child Form for Mother:  This form is to be completed by the physician for the employee going out on maternity leave.
• Birth of Child Form for Father:  This form is to be completed by the physician for the employee going out on paternity leave.
• Return to Work Authorization:  This form is to be completed by the physician before the employee out on FMLA may return to work.
• Certification Military Leave:  This form is to be completed by the employee who would like to request leave due to a military family member who is called into active duty.
• Certification of Illness for Military:  This form is to be completed by the employee who would like to request leave to care for a military family member due to a serious injury or illness.