THE FAMILY & MEDICAL LEAVE ACT (FMLA)

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1 THE FAMILY & MEDICAL LEAVE ACT (FMLA) Policy The Family and Medical Leave Act (FMLA) provides eligible employees with up to 12 work weeks of protected leave each year for specified family and medical reasons. The FMLA seeks to accomplish these purposes in a manner that accommodates the legitimate interests of employers and minimizes the potential for employment discrimination. Note: The eligibility and entitlements are defined differently under Federal and State law. This policy basically reflects Federal law; however, if an employee is eligible for provisions in the State law, these will be discussed with each individual separately. Federal and State law will run concurrently. Eligibility Employees are entitled to FMLA benefits if they: Have been employed by the City of Racine for at least 12 months; and Have worked at least 1,250 hours during the 12 months prior to the start of the FMLA leave FMLA Qualifying Events and Amount of Leave Eligible employees may take up to a total of 12 work weeks of FMLA leave in a calendar year for the following qualifying events: The birth of a child and to care for the newborn child; The placement with the employee of a child for adoption or foster care and to care for the newly placed child; To care for the employee s spouse, child, or parent with a serious health condition (Note: Under Wisconsin FMLA, an employee may take up to 2 work weeks for a domestic partner, a parent-in-law and domestic partners parents); For a qualifying exigency arising out of the fact that an employee s spouse, child or parent is on active duty or has been notified of an impending call or order to active duty as a member of the National Guard or reserves in support of a contingency operation; For the employee s own serious health condition that renders the employee unable to perform his/her job. Twelve weeks of family leave can be utilized by an employee whose spouse, child, or parent has been called to active duty to make arrangements for child care, make financial and legal arrangements, attend counseling, attend official ceremonies or programs where the military requests participation of the family member, to attend to farewell or arrival arrangements, or to attend to affairs caused by the missing status or death of a service member. Eligible employees may take up to a total of 26 work weeks of FMLA leave in a calendar year to care for a spouse, child, parent, or next of kin who is a member of the Armed Forces who suffered an injury or illness while on active duty that renders the person unable to perform the duties of the member s office, grade, rank, or rating. If an employee takes paid sick leave for a condition that progresses into a serious health condition, the City may designate all or some portion of the related leave as taken under this policy to the extent that the earlier leave meets the necessary qualifications. Leave qualifying for both Wisconsin and Federal FMLA leave count against an employee s entitlement under both laws and will run concurrently. Qualified leave taken under Worker s Compensation will also run concurrently with Wisconsin and Federal FMLA leave.

2 Leave Duration An eligible employee can take up to twelve (12) work weeks of leave during any twelve (12) month period. The City will calculate the twelve (12) month period using the calendar year. Each time an employee takes a leave, the City will compute the amount of leave the employee has taken under the policy and subtract it from the twelve (12) weeks of leave available, and the balance remaining is the amount the employee is entitled to take at that time. Husband & Wife If a husband and wife both work for the City and each wishes to take a leave for the birth, adoption, or placement of a child, or to care for a parent or child with a serious health condition, the husband and wife, combined, may only take a total of twelve (12) weeks of leave. Non-continuous or Intermittent Leave Employees are permitted to take leave on an intermittent (blocks of time) or reduced work schedule: When it is medically necessary to care for a family member with a serious health condition or because of the employee s serious health condition; When it is necessary to care for a family member or next of kin who suffered an injury or illness while on active duty; To care for a newborn, adopted or foster child. Federal FMLA leave for the birth or placement of a child for adoption or foster care may not be taken in non-continuous increments unless approved by the City. Under the Wisconsin FMLA, the last increment of leave for the birth or adoption of a child must begin within 16 weeks of that birth or placement. Medical or family caretaking leave should be planned so as not to unduly disrupt the City s operations. The City allows for intermittent leave to be taken in no less than one hour increments or, under certain circumstances, may use the leave to reduce the work week or work day, resulting in a reduced hour schedule. In all cases, the leave may not exceed a total of twelve (12) weeks in a twelve (12) month period. When requesting an intermittent leave or reduced work schedule, the City AND employee must mutually agree to the schedule before the leave begins. If this is not possible, the employee must prove the use of the leave is medically necessary. Requesting a Leave An employee requesting leave under this policy must complete a Family and Medical Leave of Absence Request Form and forward it to the Human Resources Department. The employee must request the leave at least 30 days in advance. If it is not possible to give 30 days notice, the employee must give as much notice as practicable. An employee undergoing planned medical treatment is required to make a reasonable effort to schedule the treatment to minimize disruptions to the City s operations. If an employee fails to provide 30 days notice for foreseeable leave with no reasonable excuse for the delay, the leave request may be delayed or denied until at least 30 days from the date the City receives the notice. Failure to provide timely notice allows the City to count any absences during the delay as non-fmla absences and apply the attendance policy.

3 While on leave, employees are required to report periodically to their supervisor regarding the status of the medical condition and their intent to return to work. Calling in sick is not enough to trigger the FMLA requirements. When an employee seeks leave due to a particular FMLA-qualifying condition for which the City has previously provided FMLA leave to the employee, the employee must specifically reference either the qualifying reason for the leave or the need for FMLA leave. Certification of the Serious Health Condition If the requested leave is for a family member s or the employee s serious health condition, the employee must submit a medical certification from the employee s or the family member s health care provider. The employee must respond to this requirement within fifteen (15) days or provide a reasonable explanation for the delay. Certification of the serious health condition shall include: The date when the condition began, its expected duration, diagnosis, and a brief statement of treatment. For leave for an employee s own serious health condition, the certification must include a statement that the employee is unable to perform work of any kind or is available for light duty (list restrictions and recommend accommodations). (Note: The Human Resources Department has a City of Racine Family and Medical Leave Health Care Provider Certification form which may be attached to the response for FMLA for completion by the health care provider). If the medical certification is insufficient or incomplete, the employee will be provided with a list of what information is still needed and will have seven days in which to provide the information. If the employee does not provide the information within seven days, the leave can be denied. The city also reserves the right, once the leave begins, to ask for the attending physician to complete a City of Racine Family and Medical Leave Health Care Provider Certification form periodically regarding the employee s status and intent to return to work. Recertification may be requested no more often than every 30 days in most cases. However, recertification may be required at any time if an extension to a leave is requested, circumstances described in the last certification have changed (such as a pattern of absences around an employee s scheduled days off), or the City receives information casting doubt on the employee s stated reason for an absence or the continuing validity of the last certification (such as an employee observed engaging in activities that are inconsistent with a need for time off due to the certified condition). If the employee plans to take intermittent leave or work a reduced work schedule, the certification must also include dates and the duration of treatment and a statement of medical necessity for taking an intermittent leave or work a reduced schedule. The City has the right to ask for a second opinion if it has reason to doubt the certification. The City will pay for the employee to get a certification from a second physician, which the City will select. If necessary to resolve a conflict between the original physician and second opinion, the City will require the opinion of a third physician. The City and employee will jointly select the physician and the City will pay for the opinion. This third opinion will be considered as binding and final. Use of Paid or Unpaid Leave Under Wisconsin law, an employee has the option to substitute accrued, but unused vacation, comp time, or sick leave to remain in a paid status. However, under Federal law, the city may require substitution of vacation, comp time, or sick leave. The city will allow an employee to take up to 2 weeks (10 days) of unpaid leave. For the remainder of the leave, the city will require the substitution of accrued vacation, comp time, and/or sick time. Note: Police and Fire personnel where holidays are an accrued benefit, may substitute holiday pay during a FMLA leave or holiday substitution may be required.

4 Employment Status & Benefits During the Leave While the employee is on leave, the City will continue the employee s benefits governed by either his/her labor contract or non-rep manual. Other benefit deduction(s): While on paid leave, benefit deductions will continue through payroll deductions. While on an unpaid leave, the employee is responsible for the payment of other benefit premiums when required. If payments do not continue, the City will discontinue these benefits during the leave or will recover the payments at the end of the leave period. Employment Status After the Leave An employee who takes leave under this policy will be able to return to the same job or to a job with equivalent status, pay, benefits, and other employment terms. The position will be the same or one which entails substantially equivalent skill, effort, responsibility, and authority (provided the employee is physically capable of performing the job). Return to Work An employee returning from FMLA for their own serious health condition must provide a fitness for duty certification/physician s statement releasing the employee back to full or restricted duty. If returning to restricted duty, the return to work slip should indicate the limitations and suggested accommodations, as well as the duration of the restrictions. You may be asked to have your physician complete an Attending Physician Report Form which allows your physician to be specific on the restrictions. Definitions: Child Biological, adopted, or foster child, stepchild, legal ward or, under the Federal FMLA, the child of a person having day-to-day care of the child, or a child of a person standing in loco parentis, who is under 18 years of age or 18 years of age and older and incapable of self-care because of a serious health condition. Spouse Husband and wife (does not include unmarried partners). Domestic Partner Covered under Wisconsin FMLA, includes same-sex couples who are registered in their county of residence and same-sex and opposite-sex couples who are not required to register. To qualify as registered domestic partners, the couple must be at least 18 years of age and capable of consenting to the relationship, may not be married to or in a domestic partnership with another individual, must share a common residence, must not be more closely related than second cousins and must be members of the same sex. To qualify as domestic partners without registration, the couple must be at least 18 years of age and capable of consenting to the relationship, must not be married to or in a domestic partnership with another individual, must share a common residence, must not be related in a way that would prohibit marriage under Wisconsin law, must consider themselves to be members of each other s immediate family and must agree to be responsible for each other s basic living expenses. Immediate Family Member The employee s child, spouse, or parent (does not include brothers or sisters, and, under Federal law, does not include parents-in-law). Covered Service Member - A 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 treatment status, or is otherwise on the temporary disability retired list, for a serious injury or illness. Next of Kin Used with respect to an individual, means the nearest blood relative of that individual.

5 Parent Biological parent, foster parent, adoptive parent, stepparent or legal guardian of an employee, or parentin-law or domestic partners parent under the Wisconsin FMLA. Qualifying Exigency under Military Leave A non-medical activity that is directly related to the covered military member s active duty or call to active duty status. For an activity to qualify as an exigency, it must fall within one of seven categories of activity: short-notice deployment (leave permitted up to seven days if the military member receives seven or less days notice of a call to active duty), military events and related activities, certain temporary childcare arrangements and school activities (but not ongoing childcare), financial and legal arrangements, counseling, rest and recuperation (leave permitted up to five days when the military member is on temporary rest and recuperation leave), and post-deployment military activities. Incapable of Self-Care - The individual requires assistance or supervision to provide self-care in three or more of the activities of daily living (i.e. grooming, hygiene, bathing, dressing, eating) or instrumental activities of daily living (i.e. cooking, cleaning, shopping, utilizing public transportation, paying bills, maintaining a residence, using telephones and directories, and using a post office). Serious Health Condition An illness, injury, impairment, or physical or mental condition that involves: 1. Inpatient care in a hospital, hospice, or residential medical care facility; or 2. A period of incapacity of more than three (3) consecutive calendar days including any subsequent treatment or period of incapacity relating to the same condition that requires in-person treatment by a health care provider at least once within seven days of the first date of incapacity and requires either a regimen or continuing treatment under the supervision of a health care provider or a second in-person visit to the health care provider for treatment within 30 days of the first day of incapacity; 3. Any period of incapacity due to pregnancy or prenatal care; 4. Chronic conditions requiring treatment by a health care provider at least twice per year that continue over an extended period of time and may cause episodic incapacity rather than a continuing period of incapacity (i.e. asthma, diabetes, epilepsy, etc.). 5. Permanent or long-term conditions requiring supervision for which treatment may not be effective {i.e. Alzheimer s, severe stroke, or the terminal stages of a disease); 6. Multiple treatments by or under the supervision of 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 (3) calendar days in the absence of medical intervention or treatment such as cancer (chemotherapy), severe arthritis (physical therapy), or kidney disease (dialysis).

6 STEPS FOR APPLYING FOR FAMILY OR MEDICAL LEAVE OF ABSENCE EMPLOYEE GUIDE 1. The employee should discuss the situation with his/her immediate supervisor and the Human Resources Department. If the precipitating event is foreseeable, the employee shall notify the City at least thirty days prior to the leave. If the precipitating event was unanticipated, the employee shall notify the City as soon as practicable. 2. Complete the Family and Medical Leave of Absence Request form and forward it to his/her immediate supervisor, who will then sign it and have the employee send the copy to the Human Resources Department. All requests MUST include an anticipated start and ending date. 3. The Human Resources Department will provide a Response to Request for Family and Medical Leave confirming the approval/denial of the leave, as well as salary and benefit information. 4. The employee is responsible for notifying his/her immediate supervisor AND Human Resources of any changes in his/her leave status. 5. The employee is responsible for providing recertification or status or leave reports as specified in the Response to Request for Family and Medical Leave form or when otherwise requested. 6. The employee is responsible for providing evidence of fitness for duty to certify the employee is capable of returning to work with restrictions or full duty. Delays in turning in this certification may result in delays in returning the employee to duty and pay status.

7 CITY OF RACINE FAMILY AND MEDICAL LEAVE OF ABSENCE REQUEST FORM Name: Emp ID: Department: Position: City: Zip: Address: Phone Number: ( ) I request a leave as provided by the Family and Medical Leave Act for the following period (required): Anticipated Leave Start Date: Anticipated End Date: The leave is requested for the following reason(s): The birth of my son or daughter and to care for such child; The placement of a child for adoption or foster care and to care for such child; To care for my spouse, domestic partner, son, daughter, or parent (circle one) who has a serious health condition; reason My spouse, child or parent (circle one) being on or ordered to active duty My serious health condition; reason I request to substitute the following days: Unpaid leave days days Sick leave days days Vacation days days Comp time days Holiday (Police/Fire only) days (Note: The substitution of the aforementioned days for family or medical leave will not extend or result in additional family or medical leave. Under Federal law, the City of Racine may require substitution of paid time during the length of the leave). RETURN TO WORK CERTIFICATION: I understand that if I am requesting medical leave for my serious health condition, I must not only provide the City of Racine with a certification from my health care provider as to the existence of my serious health condition, but must also provide the City of Racine with a Return to Work Certification which has been completed by my physician. I understand that failure to provide the Return to Work Certification may result in my being denied reinstatement until such document is provided to the Human Resources Department. In the event that I desire to return to work prior to the expiration of my leave, I will notify the City at least two (2) business days prior to my desired return date. ALTERNATIVE POSITION DURING LEAVE: I understand and agree that if my leave is requested to be taken on a reduced or intermittent basis and I am capable of performing work during my requested leave, the City may place me in alternative employment within the City and I hereby agree to such placement. I understand that the position that I may be placed in is only temporary. I will be returned to my position or substantially equivalent employment upon expiration of my leave (providing I am physically capable of performing the functions of the position). If you are requesting intermittent or reduced leave, please provide a schedule of the leave. The Human Resources Department will notify you if it agrees with your intermittent or reduced leave proposed schedule. Date Employee Signature Supervisor Acknowledgement Date Date Received Human Resources Signature

8 FAMILY AND MEDICAL LEAVE OF ABSENCE NOTICE OF RIGHTS The City of Racine has received your request for family and medical leave. The following information concerns your rights and obligations under the family and medical leave laws and will explain to you the following consequences of your failure to meet these obligations. Please read the following information carefully and if you have any questions, please contact the Human Resources Office. 1. Reasons for Taking Leave: Unpaid leave will be granted for any of the following reasons: For the birth of a child and to care for the newborn child; For the placement with the employee of a child for adoption or foster care and to care for the child; To care for the employee s spouse, domestic partner, child, or parent who has a serious health condition; Employee s spouse, child, or parent is on active duty or has been notified of an impending call or order to active duty in the Armed Forces; or For a serious health condition that makes an employee unable to perform his/her job. 2. Leave Entitlement: Under Federal Law, a maximum of 12 work weeks of unpaid leave in a 12 month period may be granted for any one or combination of the above reasons. The 12 month period is defined as a calendar year. 3. Other Leaves: Leaves of absence provided by contract, policy, worker s compensation, etc. run concurrent with both Federal and State FMLA. Further, both Federal and State leave run concurrent. 4. Advance Notice: The employee must provide thirty days advance notice when the leave is foreseeable or as much advanced notice as reasonable and practicable. 5. Medical Certification: If your leave is based on your serious health condition you will be asked to provide the Human Resources Department with a medical certification prepared by your health care provider. The medical certification must be provided to Human Resources within fifteen (15) days of the request or, in cases of medical emergency or unforeseen circumstances, as soon as practicable after your leave begins. If you fail to provide Human Resources with a timely medical certification, your leave request or your continuation of leave will be denied until the required certification is provided. If your leave request is based on the serious health condition of your spouse, child or parent, the Human Resources Department will require medical certification from the attending health care provider. 6. Additional Certification: Upon request of the City of Racine, you may be required to submit to another examination by a health care provider selected by the City, at the City s expense. If the second opinion differs from the initial certification, a third opinion may be obtained. The third opinion is final and binding. 7. Recertification: On a periodic basis, you must provide Human Resources with subsequent recertification that your serious health condition still prevents you from performing your job functions or that you are still needed to care for a family member with a serious health condition.

9 8. Intent to Return to Work: You may be asked by Human Resources to provide periodic reports on your status and intent to return to work. 9. Physician s Release: If you are on medical leave because of your own serious health condition, you will be asked to provide Human Resources with a physician s release signed by your health care provider before you can return to work. If you fail to provide Human Resources with a physician s release, your reinstatement will be denied until the required certification is provided. 10. Fitness for Duty Certification: You may be required to furnish a fitness for duty certification releasing you to active duty. In the event the physician is releasing you with work restrictions, the authorization must be detailed indicating any restrictions in hours and/or physical movements (twisting, bending, lifting, standing, walking, etc.). You may wish to contact your supervisor and obtain an Attending Physician Report form and job description to assist your physician in explaining work limitations or as to the types of restrictions that would impact the performance of your job functions. The City reserves the right to send you to its physician to determine your fitness for duty and ability to perform the essential job functions. Note: It is your responsibility to notify the Human Resources Department of your return to work regardless of whether a Fitness for Duty Certification or Physician s authorization is required. Failure to do so may result in payroll problems. 11. Substitution: You may request payment for unpaid leave by substituting any paid leave you have accrued at the time of your leave commencement. When paid leave is substituted for your unpaid leave, this leave will not be available to you later. You will not be entitled to additional family and/or medical leave as a result of the substitution of paid leave. 12. Maintenance of Insurance Coverage: In order to maintain your group insurance coverage(s) during your family or medical leave, you must continue to pay your share of the insurance premium(s) as you did prior to your leave. If you elect substitution of paid leave, your share of premium(s) will be paid through the normal payroll deduction method. Otherwise, the City will designate a method for collecting premium(s) when your leave is unpaid. 13. Employment Protection: Upon returning to work from family or medical leave, you will be reinstated to the position you held prior to the leave or, if your position is no longer available, to an equivalent position with equivalent pay, benefits, and other terms and conditions of employment. (Note: You must be physically/mentally capable of performing the same or equivalent duties). For additional information, please contact the Human Resources Department.

10 CITY OF RACINE FAMILY AND MEDICAL LEAVE QUESTIONS & ANSWERS Information in this packet is intended to reflect State and Federal laws regarding leaves as well as interpretations of these laws by court determinations. Family or Medical Guidelines The Family and Medical Leave Act (FMLA) is a provision created by Federal and State law that provides leave of absence from work for specific family and/or medical reasons. Provisions for leave differ under Federal and State law, however, both Federal and State benefits run concurrently. Q. What are the purposes for Family and Medical Leave? To balance the demands of the workplace with the needs of families, to promote the stability and economic security of families, and to promote national interests in preserving family integrity; and To entitle an employee to take reasonable leave for medical reasons, for the birth or adoption of a child, and for the care of a child, spouse, or parent who has a serious health condition. Q. Why should an employee always be asking for FMLA when entitled? Job protection Continued health care coverage Guaranteed time off No repercussions - cannot be disciplined, demoted, terminated or harassed So they don t lose their rights to protection under the law. Q. What are the circumstances for utilizing Family or Medical Leave? The birth of a child and to care for the child. The placement of a child with an employee for adoption or foster care. To care for a spouse, domestic partner, child, or parent if the family member has a serious health condition. Due to a spouse, child, or parent being on active duty or having been notified of an impending call or order to active duty. An employee is unable to perform the functions of the position because of the employee s own serious health condition. Q. How much leave can an eligible employee take? Employees are entitled to a maximum of 12 work weeks of unpaid leave per 12 month period. Days are calculated based on calendar days. The City will calculate the 12-month period using a calendar year. State law maximum allowances are less than Federal; however, both Federal and State leave allowances run concurrently. In the event an employee is not eligible for FMLA under federal law, state law provisions will be discussed FMLA may be taken all at once or in smaller increments where medically necessary (one hour minimum increments).

11 Q. Can leave days be taken intermittently? Intermittent leave or a reduced work schedule may be approved for the care of a seriously ill family member or because of the employee s own serious health condition as long as it is medically necessary. However, the intermittent leave or reduced work hours must be scheduled as to not unduly disrupt the City s operations. Under Federal law, an employee is not entitled to intermittent leave after the birth, adoption, or foster care of a child unless the city agrees to the intermittent leave. Under Wisconsin law, the intermittent leave must commence within 16 weeks before or after the birth or adoption. Q. What if my leave doesn t begin or end on the anticipated start date (birth of a child) or my anticipated return date needs to be extended? The City realizes that predicting a birth date is not yet an exact science or conditions arise that cause an extension of the leave. We will correct the date(s) to the actual date(s) once the leave actually begins. The Human Resources Department needs to be notified when an extension is requested so that the extension can be approved or denied, dependent upon the reason for the request. Q. What happens to benefits while on leave? The City will maintain health/dental and other benefits as if the employee were at work. The employee is responsible to provide his/her share of the plan premium(s) during an unpaid leave. In the event the leave is unpaid, payment arrangements must be made prior to the start of the leave or as soon as practicable. Q. Am I guaranteed a return to my former position? Every effort will be made to return an employee to his/her former position but the Acts do allow for the City to place an employee in an equivalent position. An equivalent position is one that has equivalent benefits, pay, and other terms and conditions of employment. Further, an employee returning from a leave for his/her own serious health condition must be able to perform all of the essential job functions of that position or the equivalent position. Q. If I am absent from work due to a work related injury, does FMLA apply? In the event the work related injury or illness qualifies under the definition of a serious health condition, as outlined under FMLA, then all provisions of the Family and Medical Leave Act apply to the worker s compensation leave. FMLA and worker s compensation leaves run concurrently. Q. How does this leave differ from traditional paid leave days? FMLA days are provided for special family or medical situations such as a birth of a child or extended illness, etc. and require prior approval. Occasional short term absences, i.e., colds, flu, etc. are not considered as days provided by the Family and Medical Leave Act but can be compensated from accrued sick leave days. Q. Can the employee substitute accumulated sick leave or vacation for leave days provided by Family or Medical Leave? The employee may substitute accumulated sick leave, vacation, comp time, or unpaid leave for Family or Medical leave purposes. However, the employee may not borrow sick leave or vacation, only the amount accrued is available. Where police and fire personnel accrue holidays, holiday time may be substituted for Family or Medical leave.

12 Employee Name: CITY OF RACINE FAMILY AND MEDICAL LEAVE REQUEST HEALTH CARE PROVIDER CERTIFICATION I,, certify that has a (Health Care Provider) (Patient) 1) Serious health condition which is an illness or injury, impairment or physical or mental condition. The following are the definitions of a Serious Health Condition under the Family and Medical Leave Act. Please indicate what category, if any, applies to this patient s condition: A) Inpatient care in a hospital, hospice, or residential medical facility B) Absence Plus Treatment (A period of incapacity of more than three consecutive calendar days that also involves one of the following circumstances (please mark appropriate line): Treatment two or more times 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. (May include course of prescription medication or therapy requiring special equipment. Does not include over-the-counter medications, bed-rest, exercise, or other activities which can be initiated without a visit to a health care provider). C) Pregnancy D) Chronic Condition Requiring Treatment. (Condition must involve all of the following circumstances): - No Yes: Requires treatment visits by a health care provider at least twice per year? - Continues over an extended period of time (recurring episodes of single underlying condition); and - May cause episodic rather than a continuing period of incapacity (asthma, diabetes, epilepsy, etc.). E) Permanent/Long-term Conditions Requiring Supervision: A period of incapacity resulting from a permanent or long-term condition for which patient must be under continuing supervision of, but not be receiving active treatment by a health care provider (Alzheimer s, severe stroke, terminal stages of a disease, etc.). F) Multiple Treatments (Non-chronic Condition): Any period of absence to receive multiple treatments by, or under the orders of, a health care provider, either for restorative surgery after an accident or injury or for a condition that would likely result in an absence of three or more consecutive calendar days in the absence of the treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis), etc. G) None of the above categories apply to this patient s condition. 2) Describe the medical facts which support your certification above including a brief statement as to how the medical facts meet the criteria of the category indicated above: 3) Date condition commenced: Probable duration of the condition: Is the patient presently incapacitated? Yes No. If yes, probable duration of patient s present incapacity? 4) If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments: If the patient will be absent from work or other daily activities on an intermittent or part-time basis because of treatment(s) also provide an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment (if known), and period required for recovery, if any: If any of these treatments will be provided by another provider of health services (i.e., physical therapist, etc.), please state the nature of such treatments:

13 If this certification is related to care for the employee s seriously ill family member, please skip the next question and proceed to question 6. 5) If medical leave is required because of the employee s own condition (including absences due to pregnancy or a chronic condition), please answer the following questions: Yes No a) Is the employee unable to perform work of any kind? b) If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee s job (the employee or the employer should supply information about the essential job functions)? If yes, please list the essential function(s) the employee is unable to perform: c) Will it be necessary for the employee to work less than a full schedule or to take leave on an intermittent basis as a result of the condition? If yes, give the probable duration d) If neither a or c applies, is it necessary for the employee to be absent from work for treatment? 6) a) If leave is required to care for a family member with a serious health condition, does the patient require assistance for basic medical, hygiene, nutritional needs, safety, or transportation? b) If response to a above is no, is the employee s presence necessary to provide psychological comfort to the patient and assist in the patient s recovery? c) If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need: Phone: Name and Address of Health Care Provider (please print or stamp) Signature of Health Care Provider Type of Practice: Date * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * To be completed by the Employee Requesting Family Leave to Care for a Family Member: State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule: Employee s Signature Date * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * AUTHORIZATION TO RELEASE INFORMATION: TO BE SIGNED BY THE PATIENT (PARENT OR GUARDIAN IF PATIENT IS A MINOR). I authorize the release of any medical information necessary to process the above request. Signature of Patient (parent or guardian if patient is a minor) Date Important Notes and Definitions 1) For purposes of this form, the information sought relates only to the condition for which the employee is requesting FMLA leave. 2) Incapacity for purposes of FMLA is defined to mean inability to work, attend school, or perform other regular daily activities due to a serious health condition, treatment therefor, or recovery therefrom. 3) Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical exams, eye exams, or dental exams.

14 ATTENDING PHYSICIAN S REPORT THE FAMILY AND MEDICAL LEAVE ACT This is to certify that (Name of Employee) Please check appropriate box : No longer suffers from a serious health condition or disability and is able to work and perform all of the functions of his/her position without restriction as of. OR May return to restricted/alternative/modified duty from to. Comments/Restriction(s) Signature of Health Care Provider Date Completed form should be returned to: Human Resources City of Racine 730 Washington Avenue, Room 2 Racine, WI 53403

15 FAMILY MEDICAL LEAVE CHECKLIST Administrative Procedure 1. When a supervisor becomes aware of an employee s potential need for FMLA, the employee should be sent to the Human Resources Department to pick up: A copy of the Family and Medical Leave of Absence Notice of Rights. A Family and Medical Leave Request form. Copies may also be obtained through Human Resources on CORI. 2. The employee must submit the Family and Medical Leave Request form to his/her immediate supervisor for signature then return the form to the Human Resources office at least 30 days in advance of the leave. If it is not possible to give 30 days notice, the employee must give as much notice as practicable. 3. Before the Human Resources office responds to the request, Human Resources personnel will determine if the employee is eligible for the leave. The employee must have been actively employed by the City for the last twelve (12) months and worked no less than 1,250 hours during the 12 month period. 4. The Human Resources Department, upon request for a leave, will complete a Response to Request for Family/Medical Leave and forward a copy to the employee and supervisor. This response will outline all of the specifics regarding the leave. 5. For leaves longer than thirty (30) days, the employee will be required to provide continuing certification every 30 days. The employee s supervisor should contact the Human Resources Department when the employee is reaching 30 days so that the appropriate forms can be forwarded to the employee. 6. An employee returning from a leave must turn in a fitness for duty certification from the attending physician. The Attending Physician s Report can be utilized by an employee s physician to document a return with restrictions. 7. Each supervisor should develop a tracking system to ensure that all of the proper documentation is sent. Track dates when the medical certification was sent and received, any attending physician s report request and response, and forward all return to work items to Human Resources. 8. If a supervisor becomes aware of an employee who might be eligible for FMLA, but has not requested the leave, notify Human Resources so that information can be forwarded to that employee AND when in doubt, call Human Resources!

16 CITY OF RACINE RESPONSE TO REQUEST FOR FAMILY/MEDICAL LEAVE To: From: Date: Re: Human Resources Department Request for Family/Medical Leave (FMLA) On, you notified us of your need to take family/medical leave for: the birth of a child or the placement of a child for adoption or foster care; or a serious health condition affecting your spouse, domestic partner, child, parent for which you need to provide care; or your spouse, child, parent being on or being ordered to active duty; or your own serious health condition that will render you unable to perform your job. (Worker s Compensation ) You notified us that you need this leave beginning on and that you expected to return to work on or about. 1) After review, you are eligible/ not eligible for leave under FMLA. 2) The requested leave will/ will not be counted against your FMLA entitlement. 3) You will/ will not be required to furnish medical certification of a serious health condition. If required, you must furnish certification by (within15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted. 4) You have elected to substitute accrued paid leave for unpaid FMLA leave as follows: a) Unpaid leave days b) Substitution of sick time days c) Substitution of vacation time days d) Substitution of comp time days e) Substitution of holiday time* days *Police and Fire personnel only f) Floating holiday days 5) The City will/ will not require you to substitute accrued paid leave for unpaid FMLA. a) Unpaid leave days b) Substitution of sick time days c) Substitution of vacation time days d) Substitution of comp time days e) Substitution of holiday time* days f) Floating holiday days

17 6) Insurance and other benefits: a) Type Premium Due Date b) Type Premium Due Date c) Type Premium Due Date 7) You will/ will not be required to furnish us with periodic reports of your status and intent to return to work every thirty days while on FMLA leave. 8) You will/ will not be required to furnish a physician s release upon your return to work indicating return to full duty or restricted duty. (Restrictions must be specific). 9) You will/ will not be required to present a fitness-for-duty certificate prior to your being restored to employment. An Attending Physician s Report form is attached to aid your physician in determining your fitness for duty. You may be subject to an independent review of your fitness-for-duty. 10) Additional information HUMAN RESOURCES ONLY: Date Sent: By whom: cc: Payroll/Benefits Supervisor Medical File

18 CITY OF RACINE CERTIFICATION OF QUALIFYING EXIGENCY FOR MILITARY FAMILY LEAVE (FMLA) Employee Name: Emp. ID: Department: Instructions: Please complete the following fully and completely. FMLA permits the City 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 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. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave. * * * * Name of covered military member on active duty or called to active duty in support of a contingency operation: Name: Relationship 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 sufficient written documentation confirming the covered military member s active duty or call to active duty status in support of a contingency operation. Qualifying Reason for Leave: Describe the reason you are requesting leave due to a qualifying exigency (including the specific reason you are requesting leave): 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 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

19 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? Yes No If so, beginning and ending dates for the period of absence: 3. Will you need to be absent from work periodically to address this qualifying exigency? Yes No Estimate schedule of leave including dates of any scheduled meetings or appointments: Estimate the frequency and duration of each appointment, meeting, or leave event (i.e. 1 deployment-related meeting every month lasting 4 hours): Frequency: times per week month Duration: hours day(s) per event 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 organization), a complete and sufficient certification includes the name, address, and contact information of the individual or entity with whom you are meeting. This information may be used to verify that the information contained on this form is accurate. Name of Individual: Title: Organization: Address: Telephone: Fax: Describe nature of meeting: * * * * I certify that the information I provided above is true and correct. Signature of Employee Date

20 CITY OF RACINE CERTIFICATION FOR SERIOUS INJURY OR ILLNESSS FO COVERED SERVICEMEMBER FOR MILITARY FAMILY LEAVE (FMLA) SECTION I: For completion by the Employee Employee Name: Emp. ID: Department: Name of covered Service member (for whom employee is requesting leave to care): Relationship of Employee to Service member: Spouse Parent Child Next of Kin Is Service member a current member of the Regular Armed Forces, 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 on the Temporary Disability Retired List (TDRL)? Yes No Describe the care to be provided to the service member and an estimate of the leave needed to provide the care: SECTION II: For completion by a US Department of Defense (DOD) Health Care Provider or a Health Care Provider who is either: (1) a US Department of Veterans Affair 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. Health Care Provider Name: Address: Type of Practice/Medical Specialty: Telephone: 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: Medical Status: 1. Covered service member s medical condition is classified as: (VSI) Very Seriously Ill/Injured Illness/Injury is of such a severity that life is imminently endangered. Family members are requested at bedside immediately. (SI) Seriously Ill/Injured Illness/Injury is of such severity that there is cause for immediate concern. OTHER Ill/Injured a serious injury or illness that may render the service member medically unfit NONE OF THE ABOVE

21 2. Approximate date condition commenced: 3. Probable duration of condition and/or need for care: 4. Is the covered service member undergoing medical treatment, recuperation, or therapy? Yes No If yes, please describe medical treatment, recuperation, or therapy: Covered Service member s Need for Care by Family Member: 1. Will the service member 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 service member require periodic follow-up treatment appointments? Yes No If yes, estimate the treatment schedule: 3. Is there a medical necessity for the service member to have periodic care for these follow-up treatment appointments? Yes No 4. Is there a medical necessity for the service member 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 * * * * AUTHORIZATION TO RELEASE INFORMATION: TO BE SIGNED BY THE PATIENT I authorize the release of any medical information necessary to process the above request. Signature of Patient Date