PAGE 1 of 27 ORIGINATION: March 14, 1994 REVISION EFFECTIVE: July 15, 2010 REVIEW: July 15, 2010

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1 HR-Human Resources TITLE: Leave of Absence APPROVED: PAGE 1 of 27 ORIGINATION: March 14, 1994 REVISION EFFECTIVE: July 15, 2010 REVIEW: July 15, PURPOSE This policy establishes the circumstances and request process under which employees may be granted a leave of absence from active employment. The types of leave offered by the Hospital include the Family and Medical Leave Act (FMLA) to include Military Family Leave, Educational, Military, and Personal. The specific situation encountered by the employee will determine which type of leave request would apply. It is not intended to provide guidance for scheduling regular vacation time. This policy should be used in situations where the employee is expected to be off work for: a. A substantiated reason falling under the Family and Medical Leave Act (FMLA) to include Military Family Leave. b. Three or more work days for Personal Leave (not regular vacation time) when because of a health condition or other personal matters when an FMLA is not appropriate or the employee is not eligible. c. Any extended periods away from normal employment for Educational or Military Leave LEAVE OF ABSENCE ELIGIBILITY The four different types of leave have different eligibility and decision criteria. They are as follows: a. Family and Medical Leave Act (FMLA to include Military Family Leave: Employees eligible for this benefit are those who have been employed within the Bloomington Hospital system for at least 12-months and have worked at least 1,250-hours during the preceding 12-month period from the requested start date of the leave. The 1250-hours worked do not include the use of paid time off (PTO) hours. Time that would have been worked but for the fulfillment of National Guard or Reserve military obligations also counts toward the 12-month and 1250-hour requirements. The 12-months an employee must have been employed by the Hospital need not be consecutive months, but a break-in-service of seven years or more will cause the employee to be treated as if no prior service had occurred.

2 REVISION EFFECTIVE: April 23, 2010 Page 2 of 14 b. Military: Military Leave is granted to employees inducted or enlisted in military service and is administered in accordance with the Uniformed Services Employment and Reemployment Act (USERRA) of c. Educational & Personal: These two types of leave are considered a privilege, which may or may not be granted by the department director, depending upon the circumstances. In considering whether to approve an Educational or Personal Leave request, a department director evaluates, among other things, the following: 1) Can arrangements be made for adequate coverage during the absence? 2) Does the employee's past work performance, attendance and attitude justify granting a leave? 3) Are reasons for requesting the leave true, justifiable, and in compliance with other provisions of this policy? 4) Is it the employee's stated intention to return to work at the Hospital when the leave expires? Personal and Educational leaves may not be granted to employees who leave primary employment at the Hospital to assume a position with another employer. Any Educational or Personal Leaves that are approved do not guarantee a position or standard hours of employment to be held for the leave period. In the case of Educational and Personal Leaves, those who feel that they have been unjustly denied a leave may request a review under the formal complaint process found in Human Resources Policy HR All classifications of employees are eligible to apply for the above types of leave subject to the specific instructions indicated. However, temporary employees and those who have not completed their initial trial period will not normally be granted leave except under unusual circumstances FAMILY AND MEDICAL LEAVE ACT (FMLA) AND MILITARY FAMILY LEAVE All employees who meet the service requirements outlined in Section may be granted FMLA for the following reasons: a. For birth of a son or daughter, and to care for the newborn child. b. For placement with the employee of a son or daughter for adoption or foster care. c. To care for the employee s spouse, dependent child (under the age 18 or classified as a dependent under the Americans with Disability Act (ADA) due to a physical or mental disability), or parent with a serious health condition. NOTE 1: This applies to a., b., and c. as listed above. Parent can be biological, adoptive, step, foster or an individual who stood in loco parentis to the employee. However, current or prior in-law relationships are not covered under FMLA. NOTE 2: This applies to a., b., and c. as listed above. Son or daughter is defined as a "biological, adopted, or foster child, a stepchild, a legal ward or a child of a person standing in loco

3 REVISION EFFECTIVE: April 23, 2010 Page 3 of 14 parentis, who is under (A)18 years of age or (B)18 years of age or older and incapable of self-care because of a mental or physical disability. d. Because of a serious health condition that makes the employee unable to perform the functions of the employee s job. e. Because of Any Qualifying Exigency arising out of the fact that the employee s spouse, son, daughter, or parent is a covered National Guard or Reserve military member on active duty (or has been notified of an impending call or order to active duty) in support of a contingency operation. f. To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent, or next of kin of the service member. A serious health condition involving continuing treatment by a health care provider includes any one or more of the following: a. An incapacity requiring at least 2 or more treatments which must occur within a 30-day period from the beginning of the period of incapacity. The first visit to the Health Care Provider must be within 7 days of the beginning of incapacity. The Health Care Provider determines whether additional treatment is necessary within 30 days. b. Pregnancy or prenatal care: Any period of incapacity because of pregnancy, or for prenatal care. c. Chronic conditions: Any period of incapacity or treatment for such incapacity because of a chronic serious health condition. A chronic serious health condition is one which: (1) Requires periodic visits (defined as at least twice a year) for treatment by a health care provider, or by a nurse under direct supervision of a health care provider; (2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and (3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.). d. Permanent or long-term conditions: A period of incapacity which is permanent or long-term because of 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. e. Conditions requiring multiple treatments: Any period of absence to receive multiple treatments (including any period of recovery there 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, for: (1) Restorative surgery after an accident or other injury; or (2) A condition that would likely result in a period of incapacity of more than three consecutive, full calendar days in the absence of medical intervention or treatment, such as cancer

4 REVISION EFFECTIVE: April 23, 2010 Page 4 of 14 (chemotherapy, radiation, etc.), severe arthritis (physical therapy), or kidney disease (dialysis). f. Absences attributable to incapacity under paragraph (b) or (c) of this section qualify for FMLA leave even though the employee or the covered 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 consecutive, full calendar days. For example, an employee with asthma may be unable to report for work because of 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. The use of FMLA Leave for the birth or placement of a child for adoption or foster care must be completed within the 12-months following the date of the birth or placement. Leave Because of Qualifying Exigency for Military Leave is available to an employee when a covered military family member is on active duty or on "call or order to active duty to support a contingency operation in the military. It applies to: (1) Short-Notice Deployment; (2) Military events and related activities; (3) Childcare and school activities; (4) Financial and legal arrangements; (5) Counseling; (6) Rest and recuperation; and (7) Post-deployment activities; and (8) a catch-all category of "Additional activities" for other types of qualifying exigencies the employer and employee agree are covered. This type of leave only applies to Reserves, National Guard, and certain retired members of regular Armed Forces or National Guard. A complete and sufficient Certification of Qualifying Exigency for Military Leave form will be required to approve this type of leave. Leave to Care for a Covered Servicemember with a Serious Injury or Illness is available to employees whose family member has suffered a serious illness or injury incurred in the line of active duty for which the servicemember is (1) undergoing medical treatment, recuperation or therapy; or (2) otherwise in outpatient status, or (3) otherwise on the temporary disability retired list. Covered Servicemembers" do not include former members of the military or those on the permanent disability and retired list. "Next of kin" is defined as the servicemember's nearest blood relative, other than the servicemember's spouse, parent, son or daughter, in the following order of priority: blood relatives who have been granted legal custody, brothers and sisters, grandparents, aunts and uncles, and first cousins, unless the servicemember specifically designated in writing another blood relative. Bloomington Hospital may request reasonable documentation of the familial relationship. A complete and sufficient Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave form will be required to approve this type of leave.

5 REVISION EFFECTIVE: April 23, 2010 Page 5 of REQUEST FOR FMLA An employee requesting FMLA must complete the Request for Family and Medical Leave Act (FMLA) form. The request must state the reason for the leave as well as the anticipated start and end dates of the leave. The completed request form must then be provided to the department director, who must promptly acknowledge (by signature) the request and forward it to the Human Resources Department. To allow the Hospital to adjust work schedules, an employee intending to take FMLA because of an expected birth or adoption, or because of a planned medical treatment, must submit a request at least 30 days before the leave is to begin. If 30 days advance noticed is not given, the employee may be required to explain why the 30 days notice was not practicable. If this time frame is not followed, the start date of the FMLA may be delayed for up to the 30 days from the time of the request. The intention of this policy is to allow the department director enough time to adjust work schedules for other employees. If the FMLA is to begin within less than 30 days and is because of an emergency or an otherwise unforeseen circumstance, the employee must give notice to his or her department director or to the Human Resources Department as soon as practicable. Intermittent leave, or leave on a reduced leave schedule, must be medically necessary because of a serious health condition or a serious injury or illness. An employee shall advise the employer, upon request, of the reasons why the intermittent/reduced leave schedule is necessary and of the schedule for treatment, if applicable. The employee and supervisor shall attempt to work out a schedule for such leave that meets the employee s needs without unduly disrupting the department operations, subject to the approval of the health care provider. A member of management may place an employee on an FMLA Leave. The decision to designate leave as FMLA-qualifying must be based only on information received from the employee or the employee s spokesperson (e.g., if the employee is incapacitated, the employee s spouse, adult child, parent, Health Care Provider, etc., may provide notice to the employer of the need to take FMLA). In any circumstance where there is not sufficient information about the reason for an employee s use of leave, the member of management should contact Human Resources. A Human Resources representative will contact the employee or the spokesperson to ascertain whether leave is potentially FMLAqualifying. The Hospital may retroactively designate leave as FMLA with appropriate notice to the employee, provided that the Hospital s failure to timely designate leave does not cause harm or injury to the employee. In all cases where leave would qualify for FMLA protections, an employer and an employee can mutually agree that leave be retroactively designated as FMLA leave MEDICAL CERTIFICATION

6 REVISION EFFECTIVE: April 23, 2010 Page 6 of 14 A Certification of Health Care Provider(HCP) for Employee s or Family Member s Serious Health Condition form (or a Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave form) completed by a health care provider can accompany the Request for Family and Medical Leave Act (FMLA) or be provided within 15 calendar days if requested in writing by the Hospital and if based on the serious health condition of the employee or the employee s spouse, child or parent or covered service member. The medical certification form must state the date on which the health condition commenced, the probable duration of the condition, and the appropriate medical facts regarding the condition. If the employee is needed to care for a spouse, child or parent, the certification must so state, along with an estimate of the amount of time off that will be required. If the employee has a serious health condition, the certification must state whether the employee can perform the functions of his or her job. If not, the required restrictions and any accommodation(s) must be specifically defined. Any incomplete forms will be returned to the employee for completion so that a decision can be made considering all of the pertinent information. The hospital may request recertification no less than every 30-days and only in connection with an absence. If the minimum duration of the leave is more than 30 days, then the Hospital must wait until the minimum duration has taken place. However, if the serious health condition is expected to last an extended period, or if duration is indefinite or unknown, then the Hospital can only require recertification every six months HOSPITAL RESPONSE TO REQUEST FOR FMLA Following the acknowledgement signature and date by the department director, the Request for Family and Medical Leave Act (FMLA) and any accompanying documents should be immediately forwarded to the Human Resources Department. It will be signed and dated by a Human Resources representative to show when it was received. All paperwork will then be provided to a Human Resources representative for a response to the request within five workdays. To provide a formal response to the FMLA request, a Human Resources representative will complete the Notice of Eligibility, Rights, and Responsibilities, Family or Medical Leave Act (FMLA) form. While completing this form, the Human Resources representative may speak to the department director concerning various aspects of the response. The department director may be asked to assist in the determination of Key Employee status (discussed below), whether to require completion of a Notice of Intention to Return from Leave form (discussed below), whether to require completion of periodic reports of status, review of any previous FMLA Leave in the past 12-months, as well as any other important matters.

7 REVISION EFFECTIVE: April 23, 2010 Page 7 of 14 The completed Notice of Eligibility, Rights, and Responsibilities, Family or Medical Leave Act (FMLA) Leave form will be mailed to the employee s home address with a copy sent to the department director and a copy kept in Human Resources. The Notice of Eligibility, Rights, and Responsibilities, Family or Medical Leave Act (FMLA) Leave form will inform the employee if the employee is eligible for FMLA and if so what rights and responsibilities the employee has. The form will also indicate whether a Certification of Health Care Provider(HCP) for Employee s or Family Members Serious Health Condition form (or a Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave form or Certification of Qualifying Exigency for Military Leave form) is required, the fact that the leave is unpaid except for the use of PTO, that employee benefits will continue during the FMLA Leave, whether the employee is considered a Key Employee, and any other pieces of pertinent information. If the medical certification was included with the request, and it is complete and sufficient, a Designation Notice will also be included. The Designation Notice will indicate that the request for FMLA has been approved, denied or pended. If the FMLA is pended, more information is required to make a final designation and the information needed will be explained. The Designation Notice will also include the number of hours that are available to the employee for FMLA and what of those hours will be counted as FMLA, (if known) and if the employee will be required to submit the Notice of Intention to Return from Leave form. The department director will use the completed Designation Notice form as their criteria for tracking the total FMLA time available to the employee KEY EMPLOYEE STATUS The FMLA regulation discusses the employer obligations for employee reinstatement following an approved FMLA Leave. One area of specific concern is determining whether an employee is deemed as a Key Employee. The Hospital may deny returning a Key Employee to their current job or an equivalent job if such denial is deemed necessary to prevent substantial and grievous economic injury to the operations of the Hospital. A Key Employee is defined as a salaried (Exempt from overtime) FMLA-eligible employee who is among the highest paid 10 percent of all Hospital employees. To determine if an employee is a Key Employee or not, year-to-date earnings are divided by weeks worked by the employee (including use of any PTO hours). To meet the criteria of substantial and grievous economic injury, the Hospital may take into account its ability to temporarily replace the employee while on the FMLA Leave. If permanent replacement is unavoidable, the cost of then reinstating the employee can be considered in evaluating whether substantial and grievous economic injury will occur from restoration. Minor inconveniences and costs that the

8 REVISION EFFECTIVE: April 23, 2010 Page 8 of 14 employer would experience in the normal course of doing business would not constitute substantial and grievous economic injury ALLOWED LENGTH AND USAGE OF FMLA LEAVE Except in the case of leave to care for a covered servicemember with a serious injury or illness, the amount of FMLA Leave will be equal to the total number of hours of an employee s standard workweek, as listed in the Human Resources/Payroll computer system, multiplied by a maximum of 12-weeks. This provides a bank of hours that allows the employee to utilize the hours all at one time, or if medically required, on an intermittent basis. An eligible employee s FMLA leave entitlement is limited to a total of 26 workweeks of leave to care for a covered servicemember with a serious injury or illness. To determine eligibility and the number of available FMLA hours consider the following questions and examples: QUESTIONS: Question #1: Has the employee been employed within the Bloomington Hospital system for at least 12-months? If no, the employee is not eligible for FMLA Leave. If yes, continue. Question #2: Did the employee work 1,250-hours during the previous 12- months, within the Bloomington Hospital system, from the requested start date? If no, the employee is not eligible for FMLA Leave. If yes, continue. EXAMPLES (situations that are not for the care for a covered servicemember with a serious injury or illness): Example #1: An employee works standard hours of 80-hours per pay period, or 40-hours per week. If the employee will need to be off work for 12-weeks, their maximum total number of available FMLA hours would equal 12 x 40 = 480-hours. Example #2: An employee works standard hours of 56-hours per pay period, or 28-hours per week. If the employee will need to be off work for 12-weeks, their maximum total number of available FMLA hours would equal 12 x 28 = 336-hours. Example #3: An employee works standard hours of 40-hours per pay period, or 20-hours per week. If the employee will need to be off work for 6-weeks, their total number of available FMLA hours would equal 6 x 20 =

9 REVISION EFFECTIVE: April 23, 2010 Page 9 of hours. In this case, if medically necessary, they could request an extension of additional 6-workweeks of FMLA Leave. Another consideration for the eligible number of FMLA hours is the number of hours used, if any, during the previous 12-months. The Hospital will complete a retroactive 12-month review from the requested/actual start date of the FMLA Leave to determine if any previous FMLA time has already been used. The 12- workweeks of FMLA Leave is for all eligible conditions combined, so even FMLA Leave used for an unrelated previous condition will be deducted when calculating the available balance. As such, the amount of previous time used will reduce the current available amount. Consider the following continued example from above: The employee in Example #1 is eligible for a maximum of 480-hours of FMLA. The start date of the FMLA is June 1 st. During the look-back, it is determined that the employee was on an FMLA Leave for the previous month of November and had used 160-hours. The remaining amount of eligible time to Employee #1 for FMLA Leave is 320-hours ( ). If required by the health care provider on the Certification of Health Care Provider(HCP) for Employee s or Family Members Serious Health Condition form (or a Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave form), the employee may use their FMLA Leave on an intermittent basis. It is appropriate to use available FMLA hours on an intermittent basis in cases where an employee is only able to work a portion of their regular work day as part of recovery, scheduled and ongoing treatments for themselves or their dependent, or other medically related conditions that prevents them from working their regularly scheduled work day. Calling in sick without providing sufficient information (depending on the situation), may not trigger the Hospital s obligation to consider the time away from work as being covered by FMLA. When subsequently requesting leave for the same FMLA qualifying reason such as under an intermittent leave, the employee should specifically reference the qualifying reason or state that the absence is FMLA. If an employee is on leave to care for a spouse, child or parent who has a serious health condition and the spouse, child or parent dies, the FMLA leave will end the same day as the death occurred BENEFITS COVERAGE DURING FMLA LEAVE During a period of FMLA Leave, an employee will retain their employment benefits just as before the leave commenced. For benefits that require a payroll deduction, the employee must continue to make the contributions that are required for their employment status and level of coverage, which would be the same payroll deduction amount as when they were working. The employee may

10 REVISION EFFECTIVE: April 23, 2010 Page 10 of 14 make their contribution by either using hours from their PTO bank, arranging direct payments to the Human Resources Department during the leave, or creating a repayment schedule with the Human Resources Department once the employee returns to work from the leave. The maximum period available for repayment upon returning to work is three-times (3x) the length of the approved FMLA, thus as an example, if an employee is on a 6-week FMLA, they would be able to have up to 18-weeks to make full repayment of their missed deductions. Employees given a leave of absence prior to and extending through their 91 st day of employment will be eligible for benefits when the employee returns to regular active work as an eligible employee RESTORATION OF EMPLOYMENT FOLLOWING FMLA LEAVE An employee returning from an approved FMLA Leave will be restored to his or her position or to a position with equivalent pay, benefits, and other terms and conditions of employment. Although every attempt will be made to do so, the Hospital cannot guarantee that an employee will be returned to his or her original job. A determination as to whether a position is an equivalent position will be made by the Director of Human Resources in coordination with the department director RETURN FROM FMLA LEAVE An employee may be required to complete a Notice of Intention to Return From Family and Medical Leave Act (FMLA) Leave form and submit it to their department director as early as known and at least two-workdays prior to the date they plan on returning to work, especially if the return date is earlier than originally requested. If the form is required, this will be indicated on the Designation Notice form. If required, Directors may use the minimum two-workday notification to plan and implement necessary staffing changes and schedule the employee back to work. If the release contains work limitations or restricts what the employee may do, the department director must confer with the Director of Human Resources to determine if reasonable accommodations can be made to facilitate the employee's return FAILURE TO RETURN FROM FMLA LEAVE UPON EXPIRATION The failure of an employee to return to work upon the expiration of an FMLA Leave may subject the employee to termination unless an extension is granted. An employee wishing to request an FMLA Leave extension (if they have not already used the maximum 12-workweek equivalent) must do so in writing to the employee s department director. The completion of another Request for Family

11 REVISION EFFECTIVE: April 23, 2010 Page 11 of 14 and Medical Leave Act (FMLA) Leave form should be made prior to and as soon as the employee realizes that she or he will not be able to return at the expiration of the original leave period. The department director and the Human Resources representative will follow the same procedures to process this extension as the original request. Employees requesting a return date beyond their FMLA maximum 12-workweek may request a Personal Leave as an extension. If the department director approves the Personal Leave as an extension of the FMLA Leave, the policy and benefits of a Personal Leave will apply (discussed below). If the department director does not approve the Personal Leave, the Human Resources Department may assist the employee in his/her search for another position. Employees not seeking to maintain their employment or refusing to accept a suitable position will be considered as having voluntarily resigned, and employees not finding another position within 60-days will be terminated EDUCATIONAL LEAVE Educational Leaves are granted only where further education or training are determined to be of value to the employee in his or her position within the Hospital, or to his or her career progression within the Hospital. Educational Leaves are granted for the length of the educational program, with a maximum of 12-months allowed, less any time taken for other types of Leave to include FMLA. The maximum of all Leaves combined is 12-months. Any approved Educational Leave, regardless of length, does not provide any guarantee of restoration for a position or standard hours of employment. For this type of leave, the employee should present a formal written letter explaining the request to their department director. If the department director wishes to approve the Educational Leave, they will complete and forward to Human Resources an Employee Change Notice form, with the employee letter, listing the inclusive dates. The information will be input into the appropriate locations and the paperwork placed in the employee file PERSONAL LEAVE Personal Leaves may be granted for up to a maximum of 12-months, less any time taken for other types of Leave to include FMLA. The maximum of all Leaves combined is 12-months. Any approved Personal Leave, regardless of length, does not provide any guarantee of restoration for a position or standard hours of employment. For this type of Leave, the employee should present a formal written letter explaining the request to their department director. If the department director wishes to approve the Personal Leave, they will complete and forward to Human Resources an Employee Change Notice form, with the employee letter, listing the inclusive dates. The information will be input into the appropriate locations and the paperwork placed in the employee file.

12 REVISION EFFECTIVE: April 23, 2010 Page 12 of MILITARY LEAVE Military Leave is granted to employees inducted or enlisted in military service and is administered in accordance with the Uniformed Services Employment and Reemployment Act (USERRA) of REQUESTS FOR EXTENSION TO EDUCATIONAL OR PERSONAL LEAVE Employees needing to extend an original leave of less than the maximum length, must request the extension from their department director at least two weeks in advance of the original leave's expiration date. The only exception to this requirement is when extenuating circumstances prevent the employee from being able to do so. Employees failing to request an extension prior to the original leave's expiration are considered to have voluntarily resigned their position with the Hospital. If the Educational or Personal Leave extension is not granted by the department director, the employee may choose to return to work if there is a position available, have sixty (60) days to obtain another position, or voluntarily resign their employment. If the employee has not obtained a position at the end of the sixty (60) days, their employment will be terminated BENEFITS DURING EDUCATIONAL AND PERSONAL LEAVE If an employee is placed on an approved Personal or Educational Leave of Absence, he/she will remain eligible for coverage under the group health and dental plans as an active employee for a period not to exceed sixty (60) days from the beginning of the leave, provided he/she pays the full unsubsidized cost of the coverage for employee and/or dependents. If the employee wishes to cancel coverage, he/she must come to Human Resources to complete the appropriate paperwork. If the employee wishes to maintain coverage during the first 60-days, he/she is expected to maintain timely payment; otherwise plan coverage will be terminated. The definition of timely payment is that the employee shall not become behind in making payments greater then the full amount of two pay periods. The employee can make payment by submitting the necessary number of PTO hours knowing it will be deducted from their pay check, or arrange to make direct payment to the Human Resources Department. At the end of sixty (60) days, if the employee has not returned to work, coverage will be terminated and the employee will be eligible for continuation of coverage under COBRA. It should be understood that while COBRA coverage provides the exact same plan design/benefits, the amount to be paid by the employee

13 REVISION EFFECTIVE: April 23, 2010 Page 13 of 14 payroll deductions is not the same as when the employee is actively working. The employee will receive an at-home COBRA mailing from our Third Party Administrator to allow enrollment and payment for any of the plans. The Hospital provided life insurance coverage continues only during an FMLA Leave, as such this coverage is stopped for an Educational or Personal Leave. Whereas, the Hospital provided Long Term Disability insurance coverage will continue, knowing that an employee would have a 180-day wait period for any potential benefits, which would mean being off of work well-beyond a 12-week FMLA. For the other benefit plans that are 100% employee paid (plans offered by Bloomington Hospital but without any premium contribution from the hospital) the employee would need to arrange payment by contacting the specific vendor/insurance company. Human Resources can provide you this information upon request. PTO time accrues during a leave of absence only if the employee is receiving a paycheck for hours worked or PTO hours submitted. Hospital discounts are extended to employees and their eligible dependents during an approved leave of absence. Other Hospital benefits will be suspended while an employee is on a leave of absence. Appropriate benefits will be offered upon the employee's return to active employment, based on the standard hours of employment held by the employee MAXIMUM LEAVE TIME In all cases, the maximum of all leaves combined is 12-months. This includes leaves of absence because of Worker s Compensation PAY WHILE ON LEAVE Although all types of leave of absence are unpaid, employees may elect to use their PTO bank as a source of income RETURNING FROM EDUCATIONAL OR PERSONAL LEAVE Although every attempt will be made to do so, the Hospital cannot guarantee that an employee will be returned to his or her original job, standard hours or department. Employees should notify their department director two weeks prior to the date they would be ready to return to work unless the leave is of shorter duration than

14 REVISION EFFECTIVE: April 23, 2010 Page 14 of 14 two-weeks. Directors may use this time to determine whether there is an available position to be offered to the employee. If there is no position to return to, the employee will have sixty (60) days to find an open position within the Hospital. If the employee has not obtained a new position within the sixty (60) days, their employment will be terminated. Department directors must submit an Employee Change Notice form to the Human Resources Department one week in advance of an employee's return to work. This will change the employee from an on leave to active status. Human Resources will then mail out any appropriate paperwork for benefit eligibility based upon the employees standard hours of employment.

15 REVISION EFFECTIVE: REQUEST April 23, 2010 FOR FAMILY Page 15 AND of 14 MEDICAL LEAVE TO INCLUDEFAMILYMILITARYLEAVE(FMLA) Name: Employee Number: Department Name Department Number: Supervisor: Current Street Address: City: State: Zip Code: Home Phone: Start Date of Anticipated Leave: Expected Date of Return to Work: Please check the appropriate box: Original Request Extension Request Reason for Requested Leave: 1. Birth of the child of the employee and to care for the newborn child. 2. Placement of a child with the employee for adoption or foster care. 3. In order to care for a spouse, child*, or parent with a serious health condition. *Child must be under age 18 or be incapable of caring for self because of physical or mental disability. 4. Serious health condition of the employee which makes him/her unable to perform the essential functions of his/her position. 5. Because of a qualifying exigency arising out of the fact that a spouse, son, daughter, or parent of the employee is on active duty, or has been notified of an impending call to active duty status, in support of a contingency operation. 6. To care for a spouse, son, daughter, parent, or next of kin of a covered service member who is recovering from a serious illness or injury sustained in the line of duty on active duty is entitled to up to 26 weeks of leave in a single 12-month period to care for the service member. 1. An employee requesting leave for the employee s serious health condition or the serious Health condition of the employee s spouse, child or parent must submit a verifying medical certification form from a Health Care Provider within 15-workdays of application for leave. 2. I understand that a failure to return to work at the end of my leave period may be treated as a resignation unless an extension has been approved in writing by Bloomington Hospital. 3. Upon submission of all properly completed paperwork, you will receive a written response to your request from the Human Resources Department. Employee Signature: Date: FMLA APPLICATION ACKNOWLEDGED BY (not an approval of request): Department Director Date Human Resources Representative Date

16 1. Name of EMPLOYEE requesting FMLA: 3. Check the appropriate serious health condition (refer to next page, Definition of a Serious Health Condition ): a. Hospital Care b. Absence Plus Treatment c. Pregnancy d. Chronic Conditions Requiring Treatment at Least Twice Per Year e. Permanent/Long-term Conditions Requiring Treatment at Least Twice Per year f. Multiple Treatments (Non-Chronic Conditions) 5a. Original date of onset and anticipated duration of condition (if pregnancy, provide expected due date): 6a. Please indicate type of leave requested: Family and Medical Leave Act (FMLA) CERTIFICATION OF HEALTH CARE PROVIDER (HCP) FOR EMPLOYEE S OR FAMILY MEMBER S SERIOUS HEALTH CONDITION Must be submitted within 30 days of foreseeable leave, if leave is FMLA qualifying. 2a. Name of PATIENT: 2b. Relationship of Patient to Employee: Self Spouse Parent Dependent Child (Date of Birth) 4. Medical Facts (Describe medical facts that support certification identified in #3): 5b. Date(s) of patient s present incapacity (if different from 5a): Period of Time: Give duration of time off from work: Begin Date: End Date: Intermittent: Please estimate episodic leave: Frequency of illness episodes: Duration of illness episodes: 6b. Prescribed treatment regimen and schedule (if applicable): Office visits: # per for (# of days/weeks/months) Therapy visits: # per for (# of days/weeks/months) Surgery (date): Other treatments (type/dates): Prescription medication Referral to other providers (describe): IF FMLA IS FOR THE EMPLOYEE S OWN SERIOUS HEALTH CONDITION. HCP: PLEASE COMPLETE #7 7a. Is in-patient hospitalization of the employee required? Yes (give dates) No IF FMLA IS FOR A FAMILY MEMBER S SERIOUS HEALTH CONDITION, HCP: PLEASE COMPLETE #8; EMPLOYEE: PLEASE COMPLETE #9 8a. Will the patient require assistance for basic medical or personal needs, safety or transportation? Yes No

17 7b. Is employee unable to perform work of any kind? Yes No 7c. 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 employer should supply you with information about the essential job functions)? Yes No If yes, please list the essential functions the employee is unable to perform: 8b. If no, would the employee s presence to provide psychological comfort be beneficial to the patient or assist in the patient s recovery? Yes No 8c. Please indicate duration and frequency/schedule (if applicable) for the need for assistance specified in 8a/ 8b: 9. To be completed by EMPLOYEE requesting FMLA for 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 on a reduced leave schedule: 10a. Print Name of Health Care Provider and Type of Practice (Field of specialization, if any): Signature of Employee: Date: 10b. Print Address of Health Care Provider: Signature of Health Care Provider and Date: Office Telephone #: PATIENT MEDICAL RELEASE: Patient Signature: Date: DEFINITION OF A SERIOUS HEALTH CONDITION -Use this to complete #3 of the Certification of Health Care Provider A serious health condition means an illness, injury, impairment, or physical or mental condition that involves one of the following: a. Hospital Care --Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care. b. Absence Plus Treatment -- A period of incapacity exists if: duration of incapacity lasts more than 3 full consecutive calendar days; and (b) an in-person treatment at least once within 7 days of first day of incapacity takes place; and (c) either a regimen of continuing treatment is initiated by HCP during first treatment or a second in-person visit for treatment is scheduled (the necessity of which is determined by HCP) within 30 days of first day of incapacity c. Pregnancy --Any period of incapacity due to pregnancy or prenatal care. d. Chronic Conditions Requiring Treatments -- A chronic condition which: (a) Requires at least two 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; (b) Continues over an extended period of time, including recurring episodes of a single underlying condition; and, (c) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes or epilepsy). e. Permanent/Long-term Conditions Requiring Supervision --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. f. Multiple Treatments (Non-chronic Conditions) --Any period of absence to receive multiple treatments (including any period of recovery there from) by a healthcare 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), or kidney disease (dialysis).

18 FAMILY AND MEDICAL LEAVE ACT LEAVE (FMLA) NOTICE OF ELIGIBILITY, RIGHTS AND RESPONSIBILITES Date: To: (Employee# ) From: Human Resources Department Representative ( ) Subject: Response to Request for FMLA Leave Part A NOTICE OF ELIGIBILITY The purpose of this letter is to provide you an official response to your request for Family and Medical Leave Act (FMLA) Leave. Please read each line very carefully for specific information. On (date), you notified us of your need to take family or medical leave beginning on (start date) and that you expect the leave to continue until on or about (end date) because of: The birth of your child and in order to care for the child; The placement of a child with you for adoption or foster care; A serious health condition that makes you unable to perform the essential functions of your job; A serious health condition affecting your spouse, child, parent, for which you are needed to provide care. A military qualifying exigency arising out of your spouse, child, or parent s active duty. To care for your spouse, child, parent or next of kin who is a covered service member recovering from a serious illness or injury sustained in the line-of-duty while on active duty in the military. We have determined that you: are eligible for FMLA leave (See Part B below for Rights and Responsibilities) are not eligible for FMLA leave, because (only one reason need be checked, although you may not be eligible for other reasons): You have not met the FMLA s 12-month length of service requirement. As of the first date of requested leave, you will have worked approximately months towards this requirement. You have not met the FMLA s 1,250-hours-worked requirement. You have exhausted your FMLA leave entitlement in the applicable 12-month period. Part B- RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE As explained in Part A, you meet the eligibility requirements for taking FMLA leave and still have FMLA leave available in the applicable 12-month period. If you have not already done so you will be required to furnish a complete and sufficient Medical Certification of a Serious Health Condition. You must return the information listed below to us by. You have 15 calendar

19 days from receipt of this notice to provide this documentation; additional time may be required in some circumstances. If you are unable to provide the Medical Certification within 15 calendar days, please contact Human Resources. If sufficient information is not provided in a timely manner, your leave may be denied or delayed. We request the following information: Sufficient certification to support your request for FMLA leave. A medical certification form that sets forth the information necessary to support your request is enclosed. Sufficient documentation to establish the required relationship between you and your family member. Examples of sufficient documentation: Other information needed: If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave (only checked blanks apply): Contact Human Resources at to make arrangements to continue to make your share of the premium payments on your health insurance to maintain health benefits while you are on leave. You may make your contribution by either using hours from your PTO bank, arranging direct payments to the Human Resources Department during the leave, or creating a repayment schedule with the Human Resources Department once you return to work from the leave. The maximum period available for repayment upon returning to work is three-times (3x) the length of the approved FMLA. If payment is not made timely, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse. Because of your status within the company, you are considered a key employee as defined in the FMLA. As a key employee, restoration to employment may be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us. We have have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to us. While on FMLA Leave, you will be required to furnish Human Resources with periodic Medical Certifications or a Health Care Provider note every (e.g.: per episodic instance or a stated interval such as if on Intermittent FMLA Leave). If the circumstances of your FMLA Leave change or you are able to return to work earlier than the date indicated on this form, you will be required to notify us at least two-workdays prior to the date you intend to report to work. If your leave does qualify as FMLA you will have the following rights while on FMLA leave: You have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated as a rolling 12-month period measured backward from the date of any FMLA usage. You have a right under the FMLA for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered service member with a serious injury or illness. This single 12- month period commenced on.

20 Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work. (Must continue to pay your portion of health insurance premiums. See Responsibilities, page 2) You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment upon your return from FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not have return rights under FMLA.) If you do not return to work following FMLA leave for a reason other than: 1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave; 2) the continuation, recurrence, or onset of a covered service member s serious injury or illness which would entitle you to FMLA leave; or 3) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA leave. You have the right to have sick and/or PTO run concurrently with your unpaid leave entitlement, provided you meet any applicable requirements of the leave policy. Applicable conditions related to the substitution of paid leave are referenced or set forth below. If you do not meet the requirements for taking paid leave, you remain entitled to take unpaid FMLA leave. For a copy of conditions applicable to sick/pto leave usage please refer to the Employee Handbook available in Human Resources or HR Polices (HR-7-101) available on the BH Intranet. We have all the information necessary to determine if your leave will qualify as FMLA and a Designation Notice is included with this form. We have requested information from you as specified above. We will inform you within 5 business days of receiving this information whether or not your leave will be designated as FMLA leave and if it will count towards your FMLA leave entitlement. If you will need to extend your Leave beyond the period listed on this document, please consult the Bloomington Hospital Human Resources Policy HR for eligibility and benefit information. Depending upon the requested length of the extension, the additional time may or may not be covered under any remaining FMLA Leave entitlement. If beyond the FMLA 12-workweek equivalent, the decision of whether or not to approve another type of Leave is at the discretion of the Department Director. If you have any questions, please contact Human Resources at