MEMORANDUM. TO: GRCC Employee FROM: Human Resources SUBJECT: Family Medical Leave Act Information

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1 G R A N D R A P I D S C O M M U N I T Y C O L L E G E TO: GRCC Employee FROM: Human Resources SUBJECT: Family Medical Leave Act Information MEMORANDUM Attached is information on the Family and Medical Leave Act of Employees are eligible if they have worked for Grand Rapids Community College at least 12 months, and have worked at least 1,250 hours over the past 12 months. Various medical conditions are appropriate for Family and Medical Leave, such as continuing treatment for chronic or long term medical conditions. If FMLA leave is appropriate for you, please complete the Family and Medical Leave Request form before you begin your leave. This form needs to be complete with your signature and the signature of your supervisor. Return to your Human Resource Generalist upon completion. Also, complete the top portion of the front page of the Certification of Health Care Provider form. Include the employee s name and department, or if applicable, the patient s name and relationship to the employee. The attending physician must complete the remainder of the form. Once this form is completed by your physician, please return to your Human Resource Generalist. Your physician may fax the form to Human Resources. Attached you will find the GRCC policy on Family and Medical Leave, Information on FMLA, the Family and Medical Leave Request form, and the Certification of Health Care Provider form. If you should have any questions, please call (616) Human Resources Phone: (616) Fax: (616)

2 G R A N D R A P I D S C O M M U N I T Y C O L L E G E Grand Rapids Community College Policy Section 6.0 Personnel Subsection 6.14 Family and Medical Leave 6.14 Family and Medical Leave Pursuant to the Family and Medical Leave Act of 1993, employees who have worked for the College for at least twelve (12) months an at least 1,250 hours during the prior twelve (12) months preceding the start of the leave, may take up to (12) weeks of unpaid leave for the following reasons: 1. Birth and/or care of child of the employee; 2. Placement of a child into the employee s family by adoption or by a foster care arrangement; 3. In order to care for the employee s spouse, child or parent who has a serious health condition and 4. A serious health condition which renders the employee unable to perform the functions of the employee s position. FAMILY AND MEDICAL LEAVE PROCEDURE There are two types of unpaid leave available under the Act: Family and Medical. In the case of unpaid leave for the birth or placement of a child, (family leave) intermittent leave or working a reduced number of hours is not permitted unless both the employee and the College agree. If both spouses are employed by the College the combined leave shall not exceed twelve (12) weeks for family leaves or to care for a parent with a serious health condition. In the case of unpaid leave for serious health conditions, (medical leave) the leave may be taken intermittently or on a reduced hours basis only if such leave is medically necessary. If intermittent or reduced hours leave is required, the College may in its sole discretion temporarily transfer the employee to another job with equivalent pay and benefits that better accommodates that type of leave. Unpaid leave to care for a family member with a serious health condition is available only for an employee s spouse, child or parent. During such leaves of absence, the college will continue to pay the portion of the health insurance premiums and the employee must continue to pay his/her share of the premium. Failure of the employee to pay his/her share of the health insurance premium may result in loss of coverage. If the employee does not return to work after the expiration of the leave, the employee will be required to reimburse the college for payment of health premiums during the family leave, unless the employee does not return to work because of the presence of a serious health condition which prevents the employee from performing his/her job or circumstances beyond the control of the employee. During such leaves, the employee shall not accrue employment benefits, such as vacation pay, sick pay, pension etc. Employment benefits accrued by the employee up to the day on which the leave of absence begins will not be lost. Employees are required to use their available vacation time during the twelve (12) week family leave, and available sick days shall be used when leave is taken because of serious health conditions. NOTE: that portion of the family leave absence which is vacation time and/or sick days will be with pay according to the College s policies regarding vacation time and sick days.

3 G R A N D R A P I D S C O M M U N I T Y C O L L E G E A rolling (12) month period measured backward from the last date any leave is taken will be used. Employees who return to work from family or medical leave of absence within or on the business day following the expiration of the twelve (12) weeks are entitled to return to their job or an equivalent position without loss of benefits or pay. Except in cases of medical emergency, applications for family leaves of absence must be submitted in writing. Applications should be submitted at least thirty (30) days before the leave is to commence, or as soon as possible if thirty (30) days notice is not possible. Appropriate forms must be submitted to the Personnel Dept. to initiate the leave. Employees requesting leave for serious health conditions must provide the College with the appropriate medical certification. To return to active status, medical certification is also required. The Executive Director of Personnel will administer the rules of the Family and Medical Leave Act. Appeal of the decision of the Executive Director of Personnel should be filed with the vice President of Community Outreach and College Relations within five working days of the receipt of the written decision. (You can find this policy in the Policy Manual, beginning on page 14. Adopted September 21, 1993)

4 G R A N D R A P I D S C O M M U N I T Y C O L L E G E Family and Medical Leave (FMLA) Request Form Grand Rapids Community College Family and Medical Leave (FMLA) Request Form Name: Employee ID Number: Date: Department: Mailing Address: Home Phone: Supervisor s Name: Phone Number: Employee Group: Meet and Confer Campus Police ESP CEBA Faculty Adjunct Faculty Normal Work Hours Per Week: Anticipated Begin Date of Leave: Date of Hire: Anticipated Return to Work Date: Reason for Request: Birth and/or care of a child of the employee Placement of a child into the employee s family be adoption or by a foster care arrangement In order to care for the employee s spouse, child or parent who has a serious health condition Spouse Child Parent A serious health condition which renders the employee unable to perform the functions of the employees position I acknowledge that I have received the policy/rules relative to the Family and Medical Leave Act Employee Signature: Leave has been: Approved Denied Supervisor Signature: Human Resources Signature: Date: Date: Date: Distribution: Employee Supervisor Human Resources Payroll 143 Bostwick Avenue, NE Grand Rapids, Michigan ph: (616) 234-GRCC Grand Rapids Community College is an equal opportunity institution. GRCC is a tobacco free campus. GRCC285 1/11

5 Certification of Health Care Provider for Employee s Serious Health Condition (Family and Medical Leave Act) U.S. Department of Labor Wage and Hour Division OMB Control Number: Expires: 2/28/2015 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 Employers must generally maintain records and documents relating to medical certifications, recertifications, 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 (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 Your employer must give you at least 15 calendar days to return this form. 29 C.F.R (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:( ) Page 1 CONTINUED ON NEXT PAGE Form WH-380-E Revised January 2009

6 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): Page 2 CONTINUED ON NEXT PAGE Form WH-380-E Revised January 2009

7 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. Page 3 CONTINUED ON NEXT PAGE Form WH-380-E Revised January 2009

8 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 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 DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. Page 4 Form WH-380-E Revised January 2009

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