YOUR RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT OF 1993

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:

•   For incapacity due to pregnancy, prenatal medical care or child birth;
•   To care for the employee’s child after birth, or placement for adoption or foster care;
•   To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition; or
•   For a serious health condition that makes the employee unable to perform the employee’s job.

 

MILITARY FAMILY LEAVE ENTITLEMENTS

Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies.

Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings.

FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service member during a single 12-month period.  A covered service member is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the service member medically unfit to perform his or her duties for which the service member is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary disability retired list.

 

BENEFITS AND PROTECTION

During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the same terms as if the employee had continued to work.  Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms.

Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of any employee’s leave.

 

JOB ELIGIBILITY REQUIREMENTS

Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 50 employees are employed by the employer within 75 miles.

 

DEFINITION OF SERIOUS HEALTH CONDITION

A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities.

Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than three consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition.  Other conditions may meet the definition of continuing treatment.

 

USE OF LEAVE

An employee does not need to use this leave entitlement in one block.  Leave can be taken intermittently or on a reduced leave schedule when medically necessary.  Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations.  Leave due to qualifying exigencies may also be taken.

 

SUBSTITION OF PAID LEAVE FOR UNPAID LEAVE

Employees may choose or employers may require use of accrued paid leave while taking FMLA leave.  In order to use paid leave for FMLA leave, employees must comply with the employer’s normal paid leave policies.

 

EMPLOYEE RESPONSIBILITIES

Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable.  When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures.

Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave.  Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave.  Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified.  Employees also may be required to provide a certification and periodic recertification supporting the need for leave.

 

EMPLOYER REQPONSIBILITIES

Covered employers must inform employees requesting leave whether they are eligible under FMLA.  If they are, the notice must specify any additional information required as well as the employees’ rights and responsibilities.  If they are not eligible, the employer must provide a reason for the ineligibility.

Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee’s leave entitlement.  If the employer determines that the leave is not FMLA-protected, the employer must notify the employee.

 

UNLAWFUL ACTS BY EMPLOYERS

FMLA makes it unlawful for any employer to:

• Interfere with, restrain, or deny the exercise of any right provided under FMLA;
• Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvements in any proceeding under or relating to FMLA.

 

ENFORCEMENT

An employee may file a complaint with the U. S. Department of Labor or may bring a private lawsuit against an employer.

FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights.

 

NOTE:  FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text of this notice.  Regulations 29 C.F.R. § 825.300(a) may require additional disclosures.

If you have access to the Internet visit FLMA’s website: http://www.dol.gov/esa/whd/fmla.  

To locate your nearest Wage-Hour Office, phone our toll-free information at 1-866-487-9243 or to the website at:  http://www.wagehour.dol.gov.

For a listing of records that must be kept by employers to comply with FMLA visit the U.S. Dept. of Labor’s website: http://www.dol.gov/dol/allcfr/ESA/Title_29/Part_825/29CFR825.500.htm.

 

 

Approved:  Oct. 12, 2009, February 28, 2019        
Reviewed:  Sep. 14, 2009, Apr. 22, 2013, Jan. 21, 2019         
Revised:                            

 

Date:  ___________________

 

I, _______________________, request family and medical leave for the following reason:

(check all that apply)

          _____         for the birth of my child;

          _____         for the placement of a child for adoption or foster care;

          _____         to care for my child who has a serious health condition;

          _____         to care for my parent who has a serious health condition;

          _____         to care for my spouse who has a serious health condition;

                             or

          _____         because I am seriously ill and unable to perform the essential functions of my position.

          _____         because of a qualifying exigency arising out of the fact that my
                                ___ spouse;                                      ___ son or daughter; ___ parent is on active duty or call to active duty status in support of a
                            contingency operation as a member of the National Guard or Reserves.

          _____         because I am the ___ spouse; ___ son or daughter; ___ parent; ___ next of kin of a covered service member with a serious injury or
                             illness.

 

I acknowledge my obligation to provide medical certification of my serious health condition or that of a family member in order to be eligible for family and medical leave within 15 days of the request for certification.

I acknowledge receipt of information regarding my obligations under the family and medical leave policy of the school district.

I request that my family and medical leave begin on ___________ and I request leave as follows:  (check one)

          _____         continuous

                             I anticipate that I will be able to return to work on __________.

          _____         intermittent leave for the:

                             _____         birth of my child or adoption or foster care placement subject to agreement by the district;

                             _____         serious health condition of ___ myself, ___ parent, ___ spouse, or  ___ child when medically necessary;

                             _____         because of a qualifying exigency arising out of the fact that my  ___ spouse; ___ son or daughter; ___ parent is on active
                                                duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.

                             _____         because I am the ___ spouse; ___ son or daughter; ___ parent;

                                                ___ next of kin of a covered service member with a serious injury or illness.

 

Details of the needed intermittent leave:

                   _______________________________________________________________

                   _______________________________________________________________

                   _______________________________________________________________

 

                             I anticipate returning to work at my regular schedule on _________________.

          _____         reduced work schedule for the:

                              _____         birth of my child or adoption or foster care placement subject to agreement by the district;

                             _____         serious health condition of myself, parent, spouse, or child when medically necessary;

                              _____         because of a qualifying exigency arising out of the fact that my ___ spouse; ___ son or daughter; ___ parent is on active
                                                 duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves.

                              _____         because I am the ___ spouse; ___ son or daughter; ___ parent;

                                                ___ next of kin of a covered service member with a serious injury or illness.

 

                              Details of needed reduction in work schedule as follows:

                    _______________________________________________________________        

                   _______________________________________________________________

                     _______________________________________________________________

                            

                             I anticipate returning to work at my regular schedule on   _________________.

I realize I may be moved to an alternative position during the period of the family and medical intermittent or reduced work schedule leave.  I also realize that with foreseeable intermittent or reduced work schedule leave, subject to the requirements of my health care provider, I may be required to schedule the leave to minimize interruptions to school district operations.

While on family and medical leave, I agree to pay my regular contributions to employer-sponsored benefit plans.  My contributions will be deducted from monies owed me during the leave period.  If no monies are owed me, I will reimburse the school district by personal check or cash for my contributions.  I understand that I may be dropped from the employer-sponsored benefit plans for failure to pay my contribution.

I agree to reimburse the school district for any payment of my contributions with deductions from future monies owed to me or the school district may seek reimbursement of payments of my contributions in court.

 

I acknowledge that the above information is true to the best of my knowledge.

 

Signed  _________________________________________________________________

 

Date     _________________________________________________________________

 

 

Approved:  Oct. 12, 2009, February 28, 2019        
Reviewed:  Sep. 14, 2009, Apr. 22, 2013, Jan. 21, 2019
Revised:  ___________________                  

 

SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, re-certifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies.

 

Employer name and contact: _____________________________________________________________

 

Employee’s job title: _______________________ Regular work schedule: _______________________

 

Employee’s essential job functions: ______________________________________________________

 

Check if job description is attached: _____

 

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 20 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form. 29 C.F.R. § 825.305(b).

Your name: _______________________________________________________________________________

                        First                                         Middle                                      Last

 

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page.

 

Provider’s name and business address: ____________________________________________________

 

Type of practice / Medical specialty: _____________________________________________________

 

Telephone: (________)____________________________Fax:(_________)_______________________

 

PART A: MEDICAL FACTS                                                                                                                                                                                                                                   

1. Approximate date condition commenced: ________________________

 

Probable duration of condition: __________________________________________________________

 

Mark below as applicable:

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? ___No ___Yes. If so, dates of admission:

Date(s) you treated the patient for condition:

____________________________________________________________________________________

 

Will the patient need to have treatment visits at least twice per year due to the condition? ___No ___ Yes.

 

Was medication, other than over-the-counter medication, prescribed? ___No ___Yes.

 

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? ____No Yes____. If so, state the nature of such treatments and expected duration of treatment:

 

2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ________________

 

3. Use the information provided by the employer in Section I to answer this question. If the employer fails        to provide a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s own description of his/her job functions.

 

Is the employee unable to perform any of his/her job functions due to the condition: ____ No ____ Yes.

 

If so, identify the job functions the employee is unable to perform:

 

4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

 

 

PART B: AMOUNT OF LEAVE NEEDED

5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? ___No Yes. ___

 

            If so, estimate the beginning and ending dates for the period of incapacity: __________________

 

6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee’s medical condition? ___No ___Yes.

 

            If so, are the treatments or the reduced number of hours of work medically necessary?

             ___No ___Yes.

 

            Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

____________________________________________________________________________

            Estimate the part-time or reduced work schedule the employee needs, if any:

            _________hour(s) per day; ________ days per week from ____________through ____________

 

7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? ____No Yes____.

 

            Is it medically necessary for the employee to be absent from work during the flare-ups?     ____ No Yes____ . If so, explain:

______________________________________________________________________________

______________________________________________________________________________

 

Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):

Frequency: _____ times per       _____ week(s) month(s) _____

 

            Duration: _____ hours or ___ day(s) per episode

 

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

 

 

____________________________________________________________________________________
Signature of Health Care Provider                                                                      Date

 

 

 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records 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 20 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 COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

 

Notice to the EMPLOYER INSTRUCTIONS to the EMPLOYER:  The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a serious injury or illness of a covered servicemember to submit a certification providing sufficient facts to support the request for leave.  Your response is voluntary.  While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.310.  Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees or employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies.

 

SECTION I:  For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom the Employee Is Requesting Leave INSTRUCTIONS to the EMPLOYEE or COVERED SERVICEMEMBER:  Please complete Section I before having Section II completed.  The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a serious injury or illness of a covered servicemember.  If requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave.  29 U.S.C. §§ 2613, 2614(c)(3).  Failure to do so may result in a denial of an employee’s FMLA request.  29 C.F.R. § 825.310(f).  The employer must give an employee at least 15 calendar days to return this form to the employer.

 

SECTION II:  For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either:  (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2)  a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider INSTRUCTIONS to the HEALTH CARE PROVIDER:   The employee listed on Page 2 has requested leave under the FMLA to care for a family member who is a member of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness.  For purposes of FMLA leave, a serious injury or illness is one that was incurred in the line of duty on active duty that may render the servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating.

 

A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember’s serious injury or illness includes written documentation confirming that the covered servicemember’s injury or illness was incurred in the line of duty on active duty and that the covered servicemember is undergoing treatment for such injury or illness by a health care provider listed above.  Answer, fully and completely, all applicable parts.  Several questions seek a response as to the frequency or duration of a condition, treatment, etc.  Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient.  Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage.  Limit your responses to the condition for which the employee is seeking leave.

 

SECTION I:  For Completion by the EMPLOYEE and /or the COVERED SERVICE MEMBER for whom the Employee Is Requesting Leave:  (This section must be completed first before any of the below sections can be completed by a health care provider.)

 

PART A:  EMPLOYEE INFORMATION

 

Name and Address of Employer (this is the employer of the employee requesting leave to care for covered servicemember):

 

______________________________________________________________________________

 

Name of Employee Requesting Leave to Care for Covered Servicemember:

 

______________________________________________________________________________
                      First                                       Middle                                     Last

 

Name of Covered Servicemember (for whom employee is requesting leave to care):

 

______________________________________________________________________________
                      First                                       Middle                                     Last

 

Relationship of Employee to Covered Servicemember Requesting Leave to Care:

  Spouse          Parent          Son               Daughter         Next of Kin

 

PART B:  COVERED SERVICE MEMBER INFORMATION

 

 

1.       Is the covered service member a current member of the Regular Armed Forces, the    National Guard or Reserves?    

   Yes         No

 

If “yes,” please provide the covered service member’s military branch, rank and unit currently assigned to:  ______________________________________________________

 

 

Is the covered service member assigned to a military medical treatment facility as an outpatient or to a  unit established for the purpose of providing command control of members of the Armed Forces receiving medical care as outpatients (such as a medical hold or warrior transition unit)?  _____ Yes  _____ No.  If “yes, please provide the name of the medical treatment facility or unit:  ________________________________________

 

 

 

 

 

 

2.       Is the covered service member on the Temporary Disability Retired List (TDRL)?        _____Yes   _____No. 

 

PART C:  CARE TO BE PROVIDED TO THE COVERED SERVICE MEMBER

 

Describe the care to be provided to the covered service member and an estimate of the leave needed to provide the care: 

______________________________________________________________________________

______________________________________________________________________________

 

 

SECTION II:  For Completion by a United States Department of Defense (“DOD”) Health Care Provider or Health Care Provider who is either:  (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider. If you are unable to make certain of the military-related determinations contained below in Part B, you are permitted to rely upon determinations from an authorized DOD representative (such as a DOD recovery care coordinator).  (Please ensure that Section I above has been completed before completing this section.)  Please be sure to sign the form on the last page.

 

PART A:  HEALTH CARE PROVIDER INFORMATION

Health Care Provider’s Name and Business Address:  

_________________________________________________________________________________________

 

Type of Practice/Medical Specialty:  ___________________________________________________________

 

Please state whether you are either:  (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized private health care provider:  __________________________________________________________________

 

Telephone: (     ) ________________   Fax: (     ) ________________   Email: __________________________

 

PART B:  MEDICAL STATUS

 

1.       Covered servicemember’s medical condition is classified as (check one of the appropriate boxes):

 

             (VSI) Very Seriously Ill/Injured – Illness/Injury is of such a severity that life is imminently endangered.  Family members are requested at bedside immediately.  (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers.)         

             (SI) Seriously Ill/Injured – Illness/injury is of such severity that there is cause for immediate concern, but there is no imminent danger to life.  Family members are requested at bedside.  (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers.)

             OTHER Ill/Injured – A serious injury or illness that may render the service member medically unfit to perform the duties of the member’s office, grade, rank, or rating.

             NONE OF THE ABOVE (Note to Employee:  If this box is checked, you may still be eligible to take                            leave to care for a covered family member with a “serious health condition” under § 825.113 of the       FMLA.  If such leave is requested, you may be required to complete DOL FORM WH-380 or an employer-provided form seeking the same information.)

 

2.       Was the condition for which the covered service member is being treated incurred in line of duty on active duty in the Armed Forces?   ____ Yes   ____ No

 

3.       Approximate date condition commenced:  _______________________________________

                                                                                                                       

4.       Probably duration of condition and/or need for care:  ______________________________                                 

 

 

5.       Is the covered service member undergoing medical treatment, recuperation, or therapy?

 Yes      No                               If “yes,” please describe medical treatment, recuperation or therapy:          

 

_________________________________________________________________________

 

 

PART C:  COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER

 

1.       Will the covered servicemember need care for a single continuous period of time, including any time for treatment and recovery?

   Yes      No. 

 

          If “yes,” estimate the beginning and ending dates for this period of time: _________________________

 

2.       Will the covered service member require periodic follow-up treatment appointments? 

 

           ___Yes   ___ No.  If  “yes.” Estimate the treatment schedule:  _________________________________

 

 

 

 

3.       Is there a medical necessity for the covered service member to have periodic care for these follow-up treatment appointments?  

___ Yes   ___ No

 

 

 

4.       Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled follow-up treatment appointments (e.g., episodic flare-ups of medical condition)?  ___ Yes   ___ No.  If “yes,” please estimate the frequency and duration of the periodic care:  __________________________________________________________________________________________

 

 

__________________________________________________________________________________________

 

 

______________________________________     _____________________________________
Signature of Health Care Provider                       Date

 

       

 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If  submitted,  it  is  mandatory  for  employers  to  retain  a  copy  of  this  disclosure  in  their records for 3 years in accordance with  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 20 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 COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

 

 

Approved:  
Reviewed:  Apr. 22, 2013
Revised:     

 

Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform the employee of the amount of leave that will be counted against the employee’s FMLA leave entitlement. In order to determine whether leave is covered under the FMLA, the employer may request that the leave be supported by a certification. If the certification is incomplete or insufficient, the employer must state in writing what additional information is necessary to make the certification complete and sufficient. While use of this form by employers is optional, a fully completed Form WH-382 provides an easy method of providing employees with the written information required by 29 C.F.R. §§ 825.300(c), 825.301, and 825.305(c).________

 To:  _____________________________________________

 Date: ____________________________________________

We have reviewed your request for leave under the FMLA and any supporting documentation that you have provided.

We received your most recent information on ______________________________________________ and decided:                     

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 _____ Your FMLA leave request is approved. All leave taken for this reason will be designated as FMLA leave.

 

The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. Based on the information you have provided to date, we are providing the following information about the amount of time that will be counted against your leave entitlement:

 _____   Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will be counted against your leave entitlement: _____________________________________________

 

 _____   Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or weeks that will be counted against your FMLA entitlement at this time. You have the right to request this information once in a 30-day period (if leave was taken in the 30-day period).

 

 Please be advised (check if applicable):

_____    You have requested to use paid leave during your FMLA leave. Any paid leave taken for this reason will count against your FMLA leave entitlement.

 

 _____   We are requiring you to substitute or use paid leave during your FMLA leave.

 

 ______   You will be required to present a fitness-for-duty certificate to be restored to employment. If such certification is not timely received, your return to work may be delayed until certification is provided. A list of the essential functions of your position ___ is ___is not attached. If attached, the fitness-for-duty certification must address your ability to perform these functions.

____________________________________________________________________________________________________________

 _____ Additional information is needed to determine if your FMLA leave request can be approved:

 

_____ The certification you have provided is not complete and sufficient to determine whether the FMLA applies to your leave   request. You must provide the following information no later than ______________________________, unless it is not practicable under the particular circumstances despite your diligent good faith efforts, or your leave may be denied.
                            (Provide at least seven calendar days)

__________________________________________________________________________________________
(Specify information needed to make the certification complete and sufficient)

____________________________________________________________________________________________________________

 

_____    We are exercising our right to have you obtain a second or third opinion medical certification at our expense, and we will   provide further details at a later time.

___________________________________________________________________________________________________________

_____    Your FMLA Leave request is Not Approved

_____    The FMLA does not apply to your leave request.

_____    You have exhausted your FMLA leave entitlement in the applicable 12-month period.

____________________________________________________________________________________________________________

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

It is mandatory for employers to inform employees in writing whether leave requested under the FMLA has been determined to be covered under the FMLA. 29 U.S.C. § 2617; 29 C.F.R. §§ 825.300(d), (e). It is mandatory for employers to retain a copy of this disclosure in their records 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 – 30 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 WAGE AND HOUR DIVISION.                                                                                                                                   Form WH-382 January 2009    

 

SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a qualifying exigency to submit a certification. Please complete Section I before giving this form to your employee. Your response is voluntary, and while you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. § 825.309.

 

Employer name: __________________________________________________________________________________

 

Contact Information: _______________________________________________________________________________

 

 

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section II fully and completely. The FMLA permits an employer to require that you submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a qualifying exigency. Several questions in this section seek a response as to the frequency or duration of the qualifying exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Your response is required to obtain a benefit. 29 C.F.R. § 825.310. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at least 15 calendar days to return this form to your employer.

 

 Your Name: ____________________________________________________________________________________
                        First                                         Middle                          Last

 

 Relationship of covered military member to you: ________________________________________________________

 

 Period of covered military member’s active duty: ________________________________________________________

 

A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a covered military member’s active duty or call to active duty status in support of a contingency operation. Please check one of the following:

 ___ A copy of the covered military member’s active duty orders is attached.

 ___ Other documentation from the military certifying that the covered military member is on active duty (or has been notified of an impending call to active duty) in support of a contingency operation is attached.

 

 

___  I have previously provided my employer with sufficient written documentation confirming the covered military member’s active duty or call to active duty status in support of a contingency operation.

 

 

 

PART A: QUALIFYING REASON FOR LEAVE

1.         Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you are requesting leave):

__________________________________________________________________________________________

­­__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 

2.         A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes any available written documentation which supports the need for leave; such documentation may include a copy of a meeting announcement for informational briefings sponsored by the military, a document confirming an appointment with a counselor or school official, or a copy of a bill for services for the handling of legal or financial affairs. Available written documentation supporting this request for leave is attached.

 

            ___ Yes ___ No ___ None Available

 

PART B: AMOUNT OF LEAVE NEEDED

1.         Approximate date exigency commenced: _________________________________________________________

            Probable duration of exigency: _________________________________________________________________

 

 

2.         Will you need to be absent from work for a single continuous period of time due to the qualifying exigency? ___No ___Yes.

            If so, estimate the beginning and ending dates for the period of absence:

__________________________________________________________________________________________

 

 

3.         Will you need to be absent from work periodically to address this qualifying exigency? ___No ___ Yes.

            Estimate schedule of leave, including the dates of any scheduled meetings or appointments: ________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 

            Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel

            time (i.e., 1 deployment-related meeting every month lasting 4 hours):

           

            Frequency: _____ times per _____ week(s) _____ month(s)

           

            Duration: _____ hours ___ day(s) per event.

 

PART C:

If leave is requested to meet with a third party (such as to arrange for childcare, to attend counseling, to attend meetings with school or childcare providers, to make financial or legal arrangements, to act as the covered military member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and sufficient certification includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either the telephone or fax number or email address of the individual or entity). This information may be used by your employer to verify that the information contained on this form is accurate.

 

Name of Individual: ___________________________ Title: ___________________________________________

Organization: _________________________________________________________________________________

Address: _____________________________________________________________________________________

Telephone: (________)_________________________ Fax: (_______)____________________________________

Email: _______________________________________________________________________________________

Describe nature of meeting: ______________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

PART D:

 

I certify that the information I provided above is true and correct.

 

___________________________________________            ________________________________________
Signature of Employee                                                         Date

 

 

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records 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 20 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 AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE EMPLOYER.

 

 

 

 

 

 

                                                                                                                             Form WH-384 January 2009

 

A.      School district notice.

1. The school district will post the notice in Exhibit 414.3E1 regarding family and medical leave.
    
2. Information on the Family and Medical Leave Act and the board policy on family and medical leave, including leave provisions and employee obligations will be provided annually.  The information will be in the Board Policy provided on-line.
    
3. When an employee requests family and medical leave, the school district will provide the employee with information listing the employee’s obligations and requirements.  Such information will include:

                   a.       a statement clarifying whether the leave qualifies as family and medical leave and will, therefore, be credited to the employee’s annual
                            12-week entitlement or 26-week entitlement depending on the purpose of the leave;

                   b.       a reminder that employees requesting family and medical leave for their serious health condition or for that of an immediate family
                             member must furnish medical certification of the serious health condition and the consequences for failing to do so or proof of call to
                             active duty in the case of military family and medical leave;

                   c.       an explanation of the employee’s right to substitute paid leave for family and medical leave including a description of when the school
                             district requires substitution of paid leave and the conditions related to the substitution; and

                   d.       a statement notifying employees that they must pay and must make arrangement for paying any premium or other payments to maintain
                             health or other benefits.

B.      Eligible employees.

          Employees are eligible for family and medical leave if three criteria are met.

          1.       The school district has more than 50 employees on the payroll at the time leave is requested;

          2.       The employee has worked for the school district for at least 12 months or 52 weeks (the months and weeks need not be consecutive); and

          3.       The employee has worked at least 1,250 hours within the previous year.  Full-time professional employees who are exempt from the wage and
                    hour law may be presumed to have worked the minimum hour requirement.

If the employee requesting leave is unable to meet the above criteria, the employee is not eligible for family and medical leave.                            

C.      Employee requesting leave – two types of leave.

          1.       Foreseeable family and medical leave.

                   a.       Definition – leave is foreseeable for the birth or placement of an adopted or foster child with the employee or for planned medical
                             treatment.

                   b.       Employee must give at least 30 days notice for foreseeable leave.  Failure to give the notice may result in the leave beginning 30 days
                             after notice was received.  For those taking leave due to military family and medical leave, notice should be given as soon as possible.

                   c.       Employees must consult with the school district prior to scheduling planned medical treatment leave to minimize disruption to the school
                             district.  The scheduling is subject to the approval of the health care provider.

          2.       Unforeseeable family and medical leave.

                   a.       Definition – leave is unforeseeable, in such situations as emergency medical treatment or premature birth.

                   b.       Employee must give notice as soon as possible but no later than one to two work days after learning that leave will be necessary.

                   c.       A spouse or family member may give the notice if the employee is unable to personally give notice.

D.      Eligible family and medical leave determination.  The school district may require the employee giving notice of the need for leave to provide reasonable documentation or a statement of family relationship.

          1.       Six purposes.

                   a.       The birth of a son or daughter of the employee and in order to care for that son or daughter prior to the first anniversary of the child’s
                             birth;

                   b.       The placement of a son or daughter with the employee for adoption or foster care and in order to care for that son or daughter prior to the
                             first anniversary of the child’s placement;

                   c.       To care for the spouse, son, daughter, or parent of the employee if the spouse, son, daughter or parent has a serious health condition; or

                   d.       Employee’s serious health condition that makes the employee unable to perform the essential functions of the employee’s position.

                   e.       Because of a qualifying exigency arising out of the fact that an employee’s spouse; son or daughter; parent is on active duty or call to
                             active duty status in support of a contingency operation as a member of the National Guard or Reserves.

                   f.       Because the employee is the spouse; son or daughter; parent; next of kin of a covered service member with a serious injury or illness.

          2.       Medical certification.        

                   a.       When required:

                             (1)     Employees shall be required to present medical certification of the employee’s serious health condition and inability to perform the
                                       essential functions of the job.

                             (2)     Employees shall be required to present medical certification of the family member’s serious health condition and that it is
                                       medically necessary for the employee to take leave to care for the family member.

                             (3)     Employees shall be required to present certification of the call to active duty when taking military family and medical leave.

                   b.       Employee’s medical certification responsibilities:

                             (1)     The employee must obtain the certification from the health care provider who is treating the individual with the serious health
                                       condition.

                             (2)     The school district may require the employee to obtain a second certification by a health care provider chosen by and paid for by
                                       the school district if the school district has reason to doubt the validity of the certification an employee submits.  The second health
                                       care provider cannot, however, be employed by the school district on a regular basis.

                             (3)     If the second health care provider disagrees with the first health care provider, then the school district may require a third health
                                       care provider to certify the serious health condition.  This health care provider must be mutually agreed upon by the employee and
                                       the school district and paid for by the school district.  This certification or lack of certification is binding upon both the employee
                                       and the school district.

                   c.       Medical certification will be required 15 days after family and medical leave begins unless it is impracticable to do so.  The school
                             district may request recertification every 30 days.  Recertification must be submitted within 15 days of the school district’s request.

                   d.       Employees taking military caregiver family and medical leave to care for a family service member cannot be required to obtain a second
                             opinion or to provide recertification.

Family and medical leave requested for the serious health condition of the employee or to care for a family member with a serious health condition which is not supported by medical certification will be denied until such certification is provided.

E.      Entitlement.

          1.       Employees are entitled to 12 weeks unpaid family and medical leave per year.  Employees taking military caregiver family and medical leave
                    to care for a family service member are entitled to 26 weeks of unpaid family and medical leave but only in a single 12 month period.

          2.       Year is defined as fiscal year – beginning July 1.

          3.       If insufficient leave is available, the school district may.

                   a.       Deny the leave if entitlement is exhausted.

                   b.       Award leave available.

                   c.       Award leave in accordance with other provisions of board policy or the collective bargaining agreement.

F.       Type of Leave Requested.

          1.       Continuous – employee

          2.       Intermittent – employee requests family and medical leave for separate periods of time.

                    a.      Intermittent leave is available for:

                             _____         birth of my child or adoption or foster care placement subject to agreement by the district;

                             _____         serious health condition of myself, parent, spouse, or child when medically necessary;

                             _____         because of a qualifying exigency arising out of the fact that my spouse; son or daughter; parent is on active duty or call to
                                                active duty status in support of a contingency operation as a member of the National Guard or Reserves.

                             _____         because I am the spouse; son or daughter; parent; next of kin of a covered service member with a serious injury or illness.

                   b.       In the case of foreseeable intermittent leave, the employee must schedule the leave to minimize disruption to the school district
                             operation.

                   c.       During the period of foreseeable intermittent leave, the school district may move the employee to an alternative position with equivalent
                             pay and benefits.

                             (For instructional employees, see G below.)

          3.       Reduced work schedule – employee requests a reduction in the employee’s regular work schedule.

                   a.       Reduced work schedule family and medical leave is available for:

                             _____         birth of my child or adoption or foster care placement subject to agreement by the district;

                             _____         serious health condition of myself, parent, spouse, or child when medically necessary;

                             _____         because of a qualifying exigency arising out of the fact that my spouse; son or daughter; parent is on active duty or call to
                                                active duty status in support of a contingency operation as a member of the National Guard or Reserves.

                             _____         because I am the spouse; son or daughter; parent; next of kin of a covered service member with a serious injury or illness.

                   b.       In the case of foreseeable intermittent leave, the employee must schedule the leave to minimize disruption to the school district
                             operation.

                   c.       During the period of foreseeable intermittent leave, the school district may move the employee to an alternative position with equivalent
                             pay and benefits.  (For instructional employees, see G below.)

G.      Special Rules for Instructional Employees.

          1.       Definition – an instructional employee is one whose principal function is to teach and instruct students in a class, a small group or an
                    individual setting.  This includes, but is not limited to, teachers, coaches, driver’s education instructors and special education assistants.        

          2.       Instructional employees who request foreseeable medically necessary intermittent or reduced work schedule family and medical leave greater
                    than twenty percent of the work days in the leave period may be required to:

                   a.       Take leave for the entire period or periods of the planned medical treatment: or

                   b.       Move to an available alternative position, with equivalent pay and benefits, but not necessarily equivalent duties, for which the employee
                             is qualified.

          3.       Instructional employees who request continuous family and medical leave near the end of a semester may be required to extend the family and
                    medical leave through the end of the semester.  The number of weeks remaining before the end of a semester does not include scheduled
                    school breaks, such as summer, winter, or spring break.

                   a.       If an instructional employee begins family and medical leave for any purpose more than five weeks before the end of a semester, the
                             school district may require that the leave be continued until the end of the semester if the leave will last at least three weeks and the
                             employee would return to work during the last three weeks of the semester if the leave was not continued.

                   b.       If the employee begins family and medical leave for a purpose other than the employee’s own serious health condition during the last
                             five weeks of a semester, the school district may require that the leave be continued until the end of the semester if the leave will last
                             more than two weeks and the employee would return to work during the last two weeks of the semester.

                   c.       If the employee begins family and medical leave for a purpose other than the employee’s own serious health condition during the last
                             three weeks of the semester and the leave will last more than five working days, the school district may require the employee to continue
                             taking leave until the end of the semester.

          4.       The entire period of leave taken under the special rules is credited as family and medical leave.  The school district will continue to fulfill the
                    school district’s family and medical leave responsibilities and obligations, including the obligation to continue the employee’s health insurance
                    and other benefits, if an instructional employee’s family and medical leave entitlement ends before the involuntary leave period expires.

H.      Employee responsibilities while on family and medical leave.

          1.       Employee must continue to pay health care benefit contributions or other benefit contributions regularly paid by the employee unless
                    employee elects not to continue the benefits.

          2.       The employee contribution payments will be deducted from any money owed to the employee or the employee will reimburse the school
                    district at a time set by the superintendent.

          3.       An employee who fails to make the health care contribution payments within 30 days after they are due will be notified that the coverage may
                    be canceled if payment is not received within an additional 15 days.

          4.       An employee may be asked to re-certify the medical necessity of family and medical leave for the serious medical condition of any employee
                    or family member once every 30 days and return the certification within 15 days of the request.

          5.       The employee must notify the school district of the employee’s intent to return to work at least once each month during the leave and at least
                    two weeks prior to the conclusion for the family and medical leave.

          6.       If an employee intends not to return to work, the employee must immediately notify the school district, in writing, of the employee’s intent not
                    to return.  The school district will cease benefits upon receipt of this notification.

I.       Use of paid leave for family and medical leave.

          An employee may substitute unpaid family and medical leave with appropriate paid leave available to the employee under board policy, individual
          contracts or the collective bargaining agreement.  Paid leave includes, but is not limited to, sick leave, family illness leave, vacation and personal
          leave.  When the school district determines that paid leave is being taken for an FMLA reason, the school district will notify the employee within
          two business days that the paid leave will be counted as FMLA leave.  Upon expiration of paid leave, the family medical leave is unpaid.

 

Active Duty – duty under a call or order to active duty under a provision of law referring to in section 101(a) (13) of title 10, U.S. Code.

Common Law Marriage – according to Iowa law, common law marriages exist when there is a present intent by the two parties to be married, continuous cohabitation, and a public declaration that the parties are husband and wife.  There is no time factor that needs to be met in order for there to be a common law marriage.

Contingency Operation – has the same meaning given such term in section 101(a)(13) of title 10, U.S. Code.

Continuing Treatment – a serious health condition involving continuing treatment by a health care provider includes any one or more of the following:

•   A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from) of more than three consecutive calendar days and any subsequent treatment or period of incapacity relating to the same condition that also involves:
  • treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or in referral by, a health care provider; or
  • treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of a health care provider.
•   Any period of incapacity due to pregnancy or for prenatal care.
•   Any period of incapacity or treatment for such incapacity due to a chronic serious health condition.  A chronic serious health condition is one which:
  • requires periodic visits for treatment by a health care provider or by a nurse or physician’s assistant under direct supervision of a health care provider;
  • continues over an extended period of time (including recurring episodes of a single underlying condition); and
  • may cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
•   Any period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider.  Examples include Alzheimer’s, a severe stroke or the terminal stages of a disease.
•   Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than 3 consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Covered Service Member – a current member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness.

Eligible Employee – the district has more than 50 employees on the payroll at the time leave is requested.  The employee has worked for the district for at least 12 months and has worked at least 1,250 hours within the previous year.

Essential Functions of the Job – those functions which are fundamental to the performance of the job.  It does not include marginal functions.

Employment Benefits – all benefits provided or made available to employees by an employer, including group life insurance, health insurance, disability insurance, sick leave, annual leave, educational benefits, and pensions, regardless of whether such benefits are provided by a practice or written policy of an employer or through an “employee benefit plan.”

Family Member – individual who meets the definition of son, daughter, spouse or parent.

Group Health Plan – any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer’s employees, former employees, or the families of such employees or former employees.

Health Care Provider –

•   A doctor of medicine or osteopathy who is authorized to practice medicine or surgery by the state in which the doctor practices; or
•   Podiatrists, dentists, clinical psychologists, optometrists, and chiropractors (limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by x-ray to exist) authorized to practice in the state and performing within the scope of their practice as defined under state law; and
•   Nurse practitioners and nurse-midwives, and clinical social workers who are authorized to practice under state law and who are performing within the scope of their practice as defined under state law; and
•   Christian Science practitioners listed with the First church of Christ Scientist in Boston, Massachusetts;
•   Any health care provider from whom an employer or a group health plan’s benefits manager will accept certification of the existence of a serious health condition to substantiate a claim for benefits;
•   A health care provider as defined above who practices in a country other than the United States who is licensed to practice in accordance with the laws and regulations of that country.

In Loco Parentis – individuals who had or have day-to-day responsibilities for the care and financial support of a child not their biological child or who had the responsibility for an employee when the employee was a child.

Incapable of Self-care – the individual requires active assistance or supervision to provide daily self-care in several of the “activities of daily living” or “ADLs.”  Activities of daily living include adaptive activities such as caring appropriately for one’s grooming and hygiene, bathing, dressing, eating, cooking, cleaning, shopping, taking public transportation, paying bills, maintaining a residence, using telephones and directories, using a post office, etc.

Instructional Employee – an employee employed principally in an instructional capacity by an educational agency or school whose principal function is to teach and instruct students in a class, a small group, or an individual setting, and includes athletic coaches, driving instructors, and special education assistants such as signers for hearing impaired.  The term does not include teacher assistants or aides who do not have as their principal function actual teaching or instructing, nor auxiliary personnel such as counselors, psychologists, curriculum specialists, cafeteria workers, maintenance workers, bus drivers, or other primarily non-instructional employees.

Intermittent Leave - leave taken in separate periods of time due to a single illness or injury, rather than for one continuous period of time, and may include leave or periods from an hour or more to several weeks.

Medically Necessary – certification for medical necessity is the same as certification for serious health condition.

“Needed to Care For” – the medical certification that an employee is “needed to care for” a family member encompasses both physical and psychological care.  For example, where, because of a serious health condition, the family member is unable to care for his or her own basic medical, hygienic or nutritional needs or safety

Next of Kin - an individual's nearest blood relative

Outpatient Status - the status of a member of the Armed Forces assigned to –

• either a military medical treatment facility as an outpatient; or
• a unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients.

Parent - a biological parent or an individual who stands in loco parentis to a child or stood in loco parentis to an employee when the employee was a child.  Parent does not include parent-in-law.

Physical or Mental Disability - a physical or mental impairment that substantially limits one or more of the major life activities of an individual.

Reduced Leave Schedule - a leave schedule that reduces the usual number of hours per workweek, or hours per workday, of an employee.

Serious Health Condition -

·       An illness, injury, impairment, or physical or mental condition that involves:

• Inpatient care (i.e. an overnight stay) in a hospital, hospice or residential medical care facility including any period of incapacity (for purposes of this section, defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from), or any subsequent treatment in connection with such inpatient care; or
• Continuing treatment by a health care provider.  A serious health condition involving continuing treatment by a health care provider includes:

--      A period of incapacity (i.e., inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment for or recovery from) of more than three consecutive calendar days, including any subsequent treatment or period of incapacity relating to the same condition, that also involves:

--   Treatment two or more times by a health care provider, by a nurse or physician's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders or, or on referral by, a health care provider; or

--   Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider.

--      Any period of incapacity due to pregnancy or for prenatal care.

--      Any period of incapacity or treatment for such incapacity due to a chronic serious health condition.  A chronic serious health condition is one which:

--   Requires periodic visits for treatment by a health care provider or by a nurse or physician's assistant under direct supervision of a health care provider;

--   Continues over an extended period of time (including recurring episodes of s single underlying condition); and

--   May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).

--   A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective.  The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider.  Examples include Alzheimer's a severe stroke or the terminal stages of a disease.

--   Any period of absence to receive multiple treatments (including any period of recovery from) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

·      Treatment for purposes of this definition includes, but is not limited to, examinations to determine if a serious health condition exists and evaluation of the condition.  Treatment does not include routine physical examinations, eye examinations or dental examinations.  Under this definition, a regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition (e.g., oxygen).  A regimen of continuing treatment that includes the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed rest, drinking fluids, exercise and other similar activities that can be initiated without a visit to a health care provider, is not, by itself, sufficient to constitute a regimen of continuing treatment for purposes of FMLA leave.

·      Conditions for which cosmetic treatments are administered (such as most treatments for acne or plastic surgery) are not "serious health conditions" unless inpatient hospital care is required or unless complications develop.  Ordinarily, unless complications arise, the common cold, the flu, ear aches, upset stomach, ulcers, headaches other than migraine, routine dental or orthodontia problems, periodontal disease, etc., are examples of conditions that do not meet the definition of a serious health condition and do not qualify for FMLA leave.  Restorative dental or plastic surgery after an injury or removal of cancerous growths are serious health conditions provided all the other conditions of this regulation are met.  Mental illness resulting from stress or allergies may be serious health conditions, but only if all the conditions of this section are met.

·      Substance abuse may be a serious health condition if the conditions of this section are met.  However, FMLA leave may only be taken for treatment for substance abuse by a health care provider or by a provider of health care on referral by a health care provider.  On the other hand, absence because of the employee's use of the substance, rather than for treatment, does not qualify for FMLA leave.

·      Absence attributable to incapacity under this definition qualify for FMLA leave even though the employee or the immediate family member does not receive treatment from a health care provider during the absence, and even if the absence does not last more than three days.  For example, an employee with asthma may be unable to report for work due to the onset of an asthma attack or because the employee's health care provider has advised the employee to stay home when the pollen count exceeds a certain level.  An employee who is pregnant may be unable to report to work because of severe morning sickness.

Serious Injury or Illness - an injury or illness incurred by a member of the Armed forces, including the National Guard or Reserves in the line of duty on active duty in the Armed Forces that may render the member medically unfit to perform the duties of the member's office, grade, rank, or rating.

Son or daughter - a biological child, adopted child, foster child, stepchild, legal ward, or a child of a person standing in loco parentis.  The child must be under age 18 or, if over 18, incapable of self-care because of a mental or physical disability.

Spouse - a husband or wife recognized by Iowa law including common law marriages.

 

 

Approved: February 28, 2019        
Reviewed:  Sep. 14, 2009, Apr. 22, 2013, Jan. 21, 2019  
Revised:     Oct 12, 2009, Jan. 21, 2019