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Family Medical LeaveEmployer Instructions and FormsWhen you become aware of an employee’s need for family or medical leave* complete the following:Provide the employee with a Request for Family/Medical Leave under the FMLA form. Have theemployee complete the form and return it to their supervisor or other designated companyrepresentative for approval or denial of leave.After the completed Request for Family/Medical Leave under the FMLA form has been received andreviewed, complete the Notice of Eligibility and Rights & Responsibilities (Family and Medical LeaveAct) WH-381 form and the Designation Notice (Family and Medical Leave Act) WH-382 form, and giveto the employee via hand delivery or certified mail. If leave is due to the employee’s own serioushealth condition, or to care for a covered family member with a serious health condition, to care for acovered servicemember or veteran with a serious injury or illness or for a qualifying exigency arisingout of the fact that covered family member is on active duty, also provide the employee with theappropriate certification form (refer to WH-380E, WH-380F, WH 384, WH 385, and WH 385V). Informemployees that medical certification must be returned within 15 days of request for leave, or as soonas practicable.Employers may wish to consult with their legal counsel for advice on whether the US Department ofLabor’s Certification of Health Care Provider for Employee’s Serious Health Condition (WH 380E),Certification of Health Care Provider for Family Member’s Serious Health Condition (WH 380F),Certification of Qualifying Exigency for Military Family Leave (WH 384), Certification for Serious Injuryor Illness of Covered Servicemember for Military Family Leave (WH 385), and Certification for SeriousInjury or Illness of a Veteran for Military Caregiver Leave (WH 385V), developed by the DOL(available at http://www.dol.gov/whd/fmla/index.htm) comply with the Genetic InformationNondiscrimination Act (GINA) regulations or whether they should attach to the DOL FMLA form(s) aseparate page containing the safe-harbor language. A sample of such a form can be found at the endof this packet.If leave is granted, complete the Employee Change/Termination Form (PEO083) and submit it to thePBS Payroll Department. Note: This form must also be completed when the employee returns fromleave.If you have a consistently enforced policy which requires employees to periodically check in while onleave and have indicated this policy on the Notice of Eligibility and Rights & Responsibilities (Familyand Medical Leave Act) WH-381 form, you may wish to use the Schedule of Employee PeriodicReports During Leave form for tracking purposes.If the employee is taking leave due to their own serious health condition, and you have a consistentlyenforced policy which requires employees to provide a fitness for duty certificate prior to their return towork from leave and have indicated this policy on the Designation Notice (Family and Medical LeaveAct) WH-382 form, provide the employee with a Return to Work Medical Certification form to becompleted by the employee and the employee’s health care provider prior to returning to work.* Family/medical leave may run concurrently with workers’ compensation leave, disability leave,and/or other state or company provided leaves. For assistance in determining whether an employee’sneed for leave is covered under federal and/or state leave laws, refer to your employee handbookand/or contact your Paychex HR Solutions – PEO HR Generalist.Professional Employer Organization (PEO) Services are sold and provided by Paychex Business Solutions, LLC and itsaffiliates. Paychex, Inc. 20189/18
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Request for Family/Medical Leave under the FMLAIn order to be eligible for up to 12 weeks (or 26 weeks for Military Caregiver Leave) of unpaid leave (in a 12month period) under the Federal Family and Medical Leave Act (FMLA)*, the following criteria must be met: You have worked for the Company for at least 12 months (need not be consecutive months, butemployment periods prior to break in service of seven years or more need not be counted).You have worked at least 1,250 hours in the 12 months preceding this request for leave.At the time leave is requested, you either a) work at a worksite with 50 or more employees, or b) work at aworksite where 50 or more employees are employed by the covered employer within 75 miles of thatworksite.* State law may provide greater leave rights. Refer to your employee handbook for state and federal leavepolicies, if applicable.Employee to CompleteYou are expected to comply with the Company’s usual and customary notice and proceduralrequirements for requesting leave, absent any unusual circumstances. If your need for family/medicalleave is foreseeable, you must give at least 30 days’ advance written notice. If this is not practicable,you must give notice as soon as practicable under the facts and circumstances of your particularsituation (generally within one or two business days of learning of your need for leave).Employee NameAddressDepartmentPositionManagerStatus (select one)Full-timePart-timeDate of HireI hereby request a leave of absence effective on(date you are requesting leave to commence).My estimated return to work date is on/////.Reason for Requested Leave Birth of a child of the employee and to care for such child. Placement of a child with employee for adoption or foster care. To care for a spouse, child, or parent with a serious health condition.Family Member NameRelationshipIf family member is a child, is the child under 18 years of age? Yes Employee’s own serious health condition. No/
To handle certain qualifying exigencies arising out of the fact that the employee’s spouse, son, daughter, orparent is on duty under a call or order to active duty in the Uniformed Services. See your company’s policyfor more details regarding Military-Related FMLA Leave.Family Member NameRelationship To care for a member of the Armed Forces or a veteran with a serious injury or illness related to certaintypes of military service. Such service member must be the employee’s spouse, son, daughter, parent, ornext of kin. See your company’s policy for more details regarding Military-Related FMLA Leave.Family Member NameRelationshipAre you requesting leave on an intermittent or reduced-schedule leave? Yes NoIf "Yes," please describe your proposed schedule.Employee Signature//Date
EMPLOYEERIGHTSUNDER THE FAMILY AND MEDICAL LEAVE ACTTHE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISIONLEAVEENTITLEMENTSEligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month periodfor the following reasons: The birth of a child or placement of a child for adoption or foster care;To bond with a child (leave must be taken within 1 year of the child’s birth or placement);To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,child, or parent.An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeksof FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employeesmay take leave intermittently or on a reduced schedule.Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employeesubstitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.BENEFITS &PROTECTIONSWhile employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it withequivalent pay, benefits, and other employment terms and conditions.An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave,opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.ELIGIBILITYREQUIREMENTSAn employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must: Have worked for the employer for at least 12 months;Have at least 1,250 hours of service in the 12 months before taking leave;* andWork at a location where the employer has at least 50 employeeswithin 75 miles of the employee’s worksite.*Special “hours of service” requirements apply to airline flight crew employees.REQUESTINGLEAVEGenerally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice,an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determineif the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is orwill be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization orcontinuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for whichFMLA leave was previously taken or certified.Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that thecertification is incomplete, it must provide a written notice indicating what additional information is required.EMPLOYERRESPONSIBILITIESOnce an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, theemployer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights andresponsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated asFMLA leave.ENFORCEMENTEmployees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuitagainst an employer.The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collectivebargaining agreement that provides greater family or medical leave rights.For additional information or to file a complaint:1-866-4-USWAGE(1-866-487-9243)TTY: 1-877-889-5627WWW.WAGEHOUR.DOL.GOVU.S. Department of LaborWage and Hour DivisionWH1420a REV 04/16
Notice of Eligibility & Rights and Responsibilitiesunder the Family and Medical Leave ActU.S. Department of LaborWage and Hour DivisionDO NOT SEND TO THE DEPARTMENT OF LABOR.PROVIDE TO EMPLOYEE.OMB Control Number: 1235-0003Expires: 6/30/2023In general, to be eligible to take leave under the Family and Medical Leave Act (FMLA), an employee must have workedfor an employer for at least 12 months, meet the hours of service requirement in the 12 months preceding the leave, andwork at a site with at least 50 employees within 75 miles. While use of this form is optional, a fully completed Form WH381 provides employees with the information required by 29 C.F.R. §§ 825.300(b), (c) which must be provided within fivebusiness days of the employee notifying the employer of the need for FMLA leave. Information about the FMLA may befound on the WHD website at www.dol.gov/agencies/whd/fmla.Date: (mm/dd/yyyy)From: (Employer) To: (Employee)On (mm/dd/yyyy), we learned that you need leave (beginning on) (mm/dd/yyyy)for one of the following reasons: (Select as appropriate) The birth of a child, or placement of a child with you for adoption or foster care, and to bond with the newborn ornewly-placed child Your own serious health condition You are needed to care for your family member due to a serious health condition. Your family member is your: Spouse Parent Child under age 18 Child 18 years or older and incapable of selfcare because of a mental or physical disability A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified ofan impending call or order to covered active duty status. Your family member on covered active duty is your: Spouse Parent Child of any age You are needed to care for your family member who is a covered servicemember with a serious injury or illness. Youare the servicemember’s: Spouse Parent Child Next of kinSpouse means a husband or wife as defined or recognized in the state where the individual was married, including in a common lawmarriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which a person assumes theobligations of a parent to a child. An employee may take FMLA leave to care for an individual who assumed the obligations of a parentto the employee when the employee was a child. An employee may also take FMLA leave to care for a child for whom the employeehas assumed the obligations of a parent. No legal or biological relationship is necessary.SECTION I – NOTICE OF ELIGIBILITYThis Notice is to inform you that you are: Eligible for FMLA leave. (See Section II for any Additional Information Needed and Section III for information on your Rightsand Responsibilities.) Not eligible for FMLA leave because: (Only one reason need be checked) You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave,you will have worked approximately: towards this requirement.(months) You have not met the FMLA’s 1,250 hours of service requirement. As of the first date of requested leave, youwill have worked approximately: towards this requirement.(hours of service)Page 1 of 4Form WH-381, Revised June 2020
Employee Name: You are an airline flight crew employee and you have not met the special hours of service eligibility requirementsfor airline flight crew employees as of the first date of requested leave (i.e., worked or been paid for at least 60%of your applicable monthly guarantee, and worked or been paid for at least 504 duty hours.) You do not work at and/or report to a site with 50 or more employees within 75-miles as of the date of yourrequest.If you have any questions, please contact: (Name of employer representative)at (Contact information).SECTION II – ADDITIONAL INFORMATION NEEDEDAs explained in Section I, you meet the eligibility requirements for taking FMLA leave. Please review the informationbelow to determine if additional information is needed in order for us to determine whether your absence qualifies as FMLAleave. Once we obtain any additional information specified below we will inform you, within 5 business days, whetheryour leave will be designated as FMLA leave and count towards the FMLA leave you have available. If complete andsufficient information is not provided in a timely manner, your leave may be denied.(Select as appropriate) No additional information requested. If no additional information requested, go to Section III. We request that the leave be supported by a certification, as identified below. Health Care Provider for the Employee Qualifying Exigency Health Care Provider for the Employee’s Family Member Serious Illness or Injury (Military Caregiver Leave)Selected certification form is attached / not attached.If requested, medical certification must be returned by (mm/dd/yyyy) (Must allow at least 15calendar days from the date the employer requested the employee to provide certification, unless it is not feasible despite the employee’sdiligent, good faith efforts.)We request that you provide reasonable documentation or a statement to establish the relationship between you andyour family member, including in loco parentis relationships (as explained on page one). The information requestedmust be returned to us by (mm/dd/yyyy). You may choose to provide a simple statement of therelationship or provide documentation such as a child’s birth certificate, a court document, or documents regardingfoster care or adoption-related activities. Official documents submitted for this purpose will be returned to you afterexamination. Other information needed (e.g. documentation for military family leave): .The information requested must be returned to us by (mm/dd/yyyy).If you have any questions, please contact: (Name of employer representative)at (Contact information).SECTION III – NOTICE OF RIGHTS AND RESPONSIBILITIESPart A: FMLA Leave EntitlementYou have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family andmedical reasons, including up to 12 weeks of unpaid leave in a 12-month period for the birth of a child or placement of achild for adoption or foster care, for leave related to your own or a family member’s serious health condition, or for certainqualifying exigencies related to the deployment of a military member to covered active duty. You also have a rightPage 2 of 4Form WH-381, Revised June 2020
Employee Name:under the FMLA to take up to 26 weeks of unpaid, job-protected FMLA leave in a single 12-month period to care for acovered servicemember with a serious injury or illness (Military Caregiver Leave).The 12-month period for FMLA leave is calculated as: (Select as appropriate) The calendar year (January 1st - December 31st) A fixed leave year based on(e.g., a fiscal year beginning on July 1 and ending on June 30) 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. (Each time an employeetakes FMLA leave, the remaining leave is the balance of the 12 weeks not used during the 12 months immediately beforethe FMLA leave is to start.)If applicable, the single 12-month period for Military Caregiver Leave started on (mm/dd/yyyy).You ( are / are not) considered a key employee as defined under the FMLA. Your FMLA leave cannot be denied forthis reason; however, we may not restore you to employment following FMLA leave if such restoration will causesubstantial and grievous economic injury to us.We ( have / have not) determined that restoring you to employment at the conclusion of FMLA leave will causesubstantial and grievous economic harm to us. Additional information will be provided separately concerning your statusas key employee and restoration.Part B: Substitution of Paid Leave – When Paid Leave is Used at the Same Time as FMLA LeaveYou have a right under the FMLA to request that your accrued paid leave be substituted for your FMLA leave. This meansthat you can request that your accrued paid leave run concurrently with some or all of your unpaid FMLA leave, providedyou meet any applicable requirements of our leave policy. Concurrent leave use means the absence will count against boththe designated paid leave and unpaid FMLA leave at the same time. If y
PBS Payroll Department. Note: This form must also be completed when the employee returns from leave. If you have a consistently enforced policy which requires employees to periodically check in while on leave and have indicated this policy on the Notice
