FAMILY & MEDICAL LEAVE ACT. Table of Contents

Transcription

1 CONTRA COSTA COUNTY FAMILY & MEDICAL LEAVE ACT REVISED 4/2010

2 FAMILY & MEDICAL LEAVE ACT Table of Contents Introduction to the Family & Medical Leave Act (FMLA)...1 Posting Requirements...2 Employees Eligible for FMLA Leave...3 Permitted Reasons for FMLA Leave...4 How Much FMLA Leave are Contra Costa County Employees Entitled to?...7 What is a Serious Health Condition Entitling an Employee to FMLA Leave for Self or Qualifying Family Member?...9 What is Not a Serious Health Condition?...11 Health Care Providers...12 Designation of Leave...13 Employee Reporting Requirements...13 Required Notices...14 Workers Compensation...17 Medical Certifications...18 Requesting Recertifications...20 Employee s Intent to Return to Work...21 Fitness for Duty Reports...22 Use of Accruals...23 Maintenance of Benefits...24 Reinstatement from FMLA Leave...25 Denying Job Restoration...25 Leaves Related to Pregnancy, Childbirth & Baby-Bonding...26 Paid Family Leave...29 Leave Checklist...31

3 FAMILY & MEDICAL LEAVE ACT Appendix Family and Medical Leave Act Notice (Your Rights)...A Notice of Eligibility and Rights and Responsibilities Form...B Designation Notice Form...C Certification of Health Care Provider for Employee s Serious Health Condition Form...D Certification of Health Care Provider for Family Member s Serious Health Condition Form... E Pregnancy Disability Leave Notice... F Family Care and Medical Leave (CFRA Leave) and Pregnancy Disability Leave Notice... F Paid Family Leave Insurance Program Brochure... F Notice to Employees... F Disability Insurance Provisions Brochure... F Contra Costa Health Services Breastfeeding Brochure...G Note: The above forms can be obtained by contacting the Labor Relations Unit at (925)

4 INTRODUCTION The Family and Medical Leave Act (FMLA) provides unpaid leave to eligible employees with qualifying circumstances and ensures that employees will be reinstated to the same or equivalent position with no loss of benefits once the leave is concluded. In California, employees are also covered by the California Family Rights Act (CFRA) and the Pregnancy Disability Leave Act, each of which provide family or medical leave that can run concurrently or consecutively with the FMLA, depending on the circumstances. (See pages 8 and for clarification.) Paid Family Leave is also available to those employees who contribute to SDI (State Disability Insurance). Paid Family Leave runs concurrently with FMLA, CFRA, & PDL. A complete overview of Paid Family Leave is provided beginning at page 29. This handbook is a guide for personnel administrators in County departments on how FMLA, CFRA, and PDL are applied in Contra Costa County. For any questions or further information, please contact your representative in the County Counsel s Office or the ADA Coordinator in Risk Management. Revised April 2010 Contra Costa County Page 1 of 31 Family & Medical Leave Handbook Rev. 4/2010

5 POSTING REQUIREMENTS Each department must post a notice in a conspicuous place which explains the FMLA s major provisions and identifies procedures for filing complaints of violations. Failure to post a notice precludes the County from taking any adverse action against an employee, including denying FMLA leave for an employee s failure to give proper notice. Each department must post the federal FMLA notice at each work site. A new revised notice for immediate posting is in Appendix A. Each department must post a CFRA and PDL notice at each work site. Each department must post the notice pertaining to Unemployment Insurance, SDI and Paid Family Leave at each work site. A Paid Family Leave information brochure must be provided when any eligible employee requests a leave to care for a sick or injured family member or to bond with a new baby. SDI pamphlet DE 2515 must be provided when an employee notifies the department of the need to take time off from work due to a non-industrial medical condition. Pamphlets may be ordered at no cost from the Employment Development Department (EDD) by calling or submitting an on-line request at Samples of the above notices to be posted or distributed are located in Appendix F. Contra Costa County Page 2 of 31 Family & Medical Leave Handbook Rev. 4/2010

6 EMPLOYEES ELIGIBLE FOR FMLA LEAVE The employee has been employed by the County for at least twelve (12) months. The 12 months DO NOT need to be consecutive months; AND The employee has worked for the County at least 1,250 hours during the twelve (12) month period immediately preceding the commencement of the leave. The key determination is based on the number of hours actually worked. Unpaid and paid leaves, including, but not limited to vacation, sick leave, holidays, administrative leave, management leave, jury duty leave, long term disability, and workers compensation time, do not count toward the 1,250 hours. In determining whether an employee has worked 1250 hours, an employee returning from a National Guard or Reserve military obligation shall be credited with the hours of service that the employee would have performed but for the period of military service. Contra Costa County Page 3 of 31 Family & Medical Leave Handbook Rev. 4/2010

7 PERMITTED REASONS FOR FMLA LEAVE An employee is entitled to FMLA leave for one or more of the following circumstances: 1. Birth of an employee s child and to care for the newborn child. Eligibility ends 12 months after the birth of the child 2. Placement of a child with the employee for adoption or foster care. FMLA leave may be taken for events that are part of the adoption or foster care process, i.e., pre-placement counseling sessions, court appearances, consultation with attorneys, etc., as well as the bonding period following the placement. Eligibility ends 12 months after the placement of the child 3. To care for a spouse, parent, child or domestic partner with a serious health condition. Spouse: a partner in marriage as defined by Family Code section 300. Family Code section 300 defines marriage as a personal relation arising out of a civil contract between a man and a woman, to which the consent of the parties capable of making that contract is necessary. Consent alone does not constitute marriage. Consent must be followed by the issuance of a license and solemnization. Domestic Partner: an unmarried person, 18 years or older, to whom the employee is not related and with whom the employee resides and shares the common necessities of life. NOTE: This is the County s definition of domestic partner, which is broader than the California definition of domestic partner in Family Code section 297. Domestic partners are not covered under the FMLA, but they are covered under the CFRA and County Family Care Leave. This means that an employee who takes time off to care for a domestic partner with a serious health condition may use up to 18 weeks under CFRA/county leave and still have 12 weeks under the FMLA for another qualifying reason) Parent: a biological, foster, or adoptive parent, a stepparent, legal guardian, or any other person who stood in loco parentis to the employee when the employee was a child. A biological or legal relationship is not necessary for a person to have stood in loco parentis to the employee as a child. This term does not include parents-in-law. Child: a biological, adopted, or foster child, stepchild, legal ward, or child of an employee who stands in loco parentis to that child if the child is either under age 18 or is an adult dependent child who is incapable of selfcare because of a mental or physical disability. The employee need not be the only individual available to care for the family member. Contra Costa County Page 4 of 31 Family & Medical Leave Handbook Rev. 4/2010

8 4. The employee s own serious health condition See page 9 for definition of serious health condition See page 26 for application in situations involving pregnancy 5. Any qualifying exigency arising out of the fact that the employee s spouse, son, daughter, or parent is on covered active duty in the Armed Forces. Not covered by CFRA Includes if a military member has been notified of an impending call or order to covered active duty. Spouse: means a husband or wife as defined or recognized under State law for purposes of marriage in the State where the employee resides. In California, marriage does not apply to domestic partners. As this is an evolving area of state law, it is subject to change in the future. Currently, it does not apply to domestic partners. Covered Active Duty: For a member of the regular Armed Forces- duty during the deployment of the member with the Armed Forces to a foreign country; and For a member of the Reserves- duty during the deployment of the member with the Armed Forces to a foreign country under a call or order to active duty during a war or national emergency declared by the President or Congress. 6. To care for a covered service member with a serious injury or illness if the employee is the spouse, son, daughter, parent, or next of kin of the service member. Up to 26 work weeks of leave to care for a covered service member with a serious injury or illness during a single 12-month period. If an employee does not take all of the 26 workweeks of leave entitlement to care for a covered service member during the single 12-month period, the remaining part of the 26 workweeks of leave is forfeited. CFRA leave and County Family Care Leave only allow up 12 or 18 weeks of leave to care for a spouse, parent, child or domestic partner with a serious health condition. No other special service member leave is covered. Employees are not eligible for the 26 weeks of FMLA service member leave to care for a domestic partner or the parent or child of a domestic partner, but may still take leave for these purposes under the CFRA/County Family Care Leave to care for a domestic partner, or the parent or child of a domestic partner with a serious health condition. Single 12-month period: begins on the first day the employee takes FMLA leave to care for a covered service member and ends 12 months after that date, regardless of the method used by the County to determine the employee s FMLA leave entitlement for other qualifying reasons. Contra Costa County Page 5 of 31 Family & Medical Leave Handbook Rev. 4/2010

9 This leave is on a per-covered-service member, per-injury basis. An employee may be entitled to more than one period of 26 weeks of leave if the leave is to care for a different service member or the same service member with a subsequent injury or illness. But if there is overlap, the employee is still limited to no more than 26 workweeks of leave in a single 12-month period The 26 workweeks is a combined total of, not in addition to, the regular 12 or 18 weeks of FMLA leave for other qualifying reasons. The employee need not be the only individual or family member available to care for the covered service member. Next of Kin: means nearest blood relative Covered Service Member: A member of the Armed Forces (including the National Guard or Reserves) who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury of illness; or A veteran who is undergoing medical treatment, recuperation, or therapy, for a serious injury or illness and who was a member of the Armed Forces (including the National Guard or Reserves) at any time during the period of 5 years preceding the date on which the veteran undergoes that medical treatment, recuperation, or therapy. Veteran: means a person who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable. Serious Illness or Injury of Covered Service Member: For a member of the Armed Forces (including the National Guard or Reserves) means an injury or illness that was incurred by the member in the line of duty on active duty in the Armed Forces (or existed before the beginning of the member s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces) and that may render the member medically unfit to perform the duties of the member s office, grade, rank, or rating; and For a veteran means a qualifying injury or illness that was incurred by the member in the line of duty on active duty in the Armed Forces (or existed before the beginning of the member s active duty and was aggravated by service in the line of duty on active duty in the Armed Forces) and that manifested itself before or after the member became a veteran. NOTE: The federal regulations regarding leaves for a qualifying exigency related to covered active duty in the Armed Forces or to care for the serious injury or illness of a covered service member are still being developed. Contact your representative in the County Counsel s Office or the ADA Coordinator in Risk Management for updated information about these types of leaves and special medical certification requirements. Contra Costa County Page 6 of 31 Family & Medical Leave Handbook Rev. 4/2010

10 HOW MUCH FMLA LEAVE ARE CONTRA COSTA COUNTY EMPLOYEES ENTITLED TO? County employees, represented and unrepresented, are entitled to 18 workweeks of FMLA leave during a rolling 12-month period. Employees represented by the Deputy Sheriffs Association, District Attorney Investigators Association, Deputy District Attorneys Association, the Contra Costa County Fire Protection District Unit of IAFF Local 1230, East Contra Costa Fire Fighters Unit of IAFF Local 1230, and Contra Costa Fire Protection District s United Chief Officers Association are entitled to 12 workweeks of FMLA leave. Rolling 12-month period: is measured backward from the date an employee uses any FMLA. Each time an employee takes FMLA leave, the remaining leave entitlement is any balance of the 12 weeks which has not been used during the immediately preceding 12 months. Example #1: If an employee has taken 8 weeks of leave during the past 12 months, an additional 4 weeks of leave could be taken. Example #2: If an employee used 4 weeks of leave beginning February 1, 2008, 4 weeks beginning June 1, 2008, and 4 weeks beginning December 1, 2008, then the employee would not be entitled to any additional leave until February 1, On February 1, 2009, the employee would again be eligible for FMLA leave and would recoup 1 additional day each day worked for 4 weeks. The employee would again begin recouping additional days on June 1, 2009 and December 1, The rolling 12-month method requires constant recalculation of an employee s FMLA leave entitlement. Employees may fall in and out of FMLA protection depending on their prior usage. Example: In Example #2 above, if the employee needs 6 weeks of leave for a serious health condition beginning on February 1, 2009, only the first 4 weeks of leave would be FMLA-protected. EXCEPTION: The 12-month period for FMLA leave for an employee to care for a covered service member is measured forward from the first date that the employee s leave begins to care for the covered service member and ends 12 months after that date. Do not use the rolling 12-month method in the case of leave for a covered service member. Intermittent Leave or Reduced Work Schedule: Intermittent leave may be taken in separate blocks of time due to a single illness or injury. The FMLA leave entitlement may be taken intermittently on a regular basis or may include a reduced work schedule depending on the circumstances. Examples include taking 2 hours of leave weekly for physical therapy or working 3 days a week while being treated for a qualifying illness. Employees must make a reasonable effort to schedule intermittent leave so as not to disrupt normal work operations. Contra Costa County Page 7 of 31 Family & Medical Leave Handbook Rev. 4/2010

11 Baby Bonding Leave: Under the CFRA, employees can take intermittent leave for the care of a newborn or placement of a child for adoption or foster care. Generally, the department does not have to allow more than two requests of baby bonding leave for less than 2 week intervals. Where the parents (whether married or not) of a child are both employed by the County, FMLA leave based on the birth, adoption, or foster care of a child is limited to an aggregate for both employees together of 12 or 18 weeks during a rolling 12-month period measured backward from the date an employee uses his/her FMLA leave. Employees represented by the Deputy Sheriffs Association are not required to aggregate any of their 12 week leave entitlement. Pregnancy Disability Leave: In Contra Costa County, leave from work due to pregnancy disability may NOT run concurrently with CFRA or County family care leave. FMLA may run concurrently with pregnancy disability leave. (See page 26 for more detailed information) Where there are no complications, health care providers usually apply State Disability Insurance (SDI) criteria and presume that an employee is disabled due to her pregnancy for a period up to 4 weeks prior to the birth and for a period of 6 weeks following the birth (8 weeks following a Caesarian section). The length of time that an employee is actually disabled due to her pregnancy is determined by her health care provider and can exceed the guidelines above. If the employer provides more than four months of leave for other temporary disabilities, the same leave must also be made available to women who are disabled due to pregnancy, childbirth, or a related medical condition. The department can require medical certification for a pregnancyrelated disability leave. The department does not have the right to challenge the employee s physician in the case of pregnancy-related leave. Contra Costa County Page 8 of 31 Family & Medical Leave Handbook Rev. 4/2010

12 WHAT IS A SERIOUS HEALTH CONDITION ENTITLING AN EMPLOYEE TO FMLA LEAVE FOR SELF OR QUALIFYING FAMILY MEMBER? The FMLA defines serious health condition as an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment as specified below: 1. Inpatient Care: means an overnight stay in a hospital, hospice, or residential medical care facility, including any period of incapacity or any subsequent treatment in connection with such inpatient care. a. Incapacity: means inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery there from. b. Treatment: includes, but is not limited to, examinations to determine if a serious health condition exists and evaluations of the condition. i. Does Not Include: routine physical, eye, or dental examinations; cosmetic treatments (unless inpatient hospital care is required or complications develop). OR 2. Continuing treatment by a health care provider. A serious health condition involving continuing treatment by a health care provider includes any one or more of the following: a. A period of incapacity (as defined above) of more than 3 consecutive full calendar days, and any subsequent treatment or period of incapacity relating to the same condition, that also involves: OR i. Treatment 2 or more times, within 30 days of the first day of incapacity, unless extenuating circumstances exist, by a health care provider, by a nurse under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; OR ii. Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider. The requirements in (i.) and (ii.), above, require that the treatment by a health care provider be an in-person visit. The first (or only) visit must take place within 7 days of the first day of incapacity. Contra Costa County Page 9 of 31 Family & Medical Leave Handbook Rev. 4/2010

13 b. Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. The chronic condition requires: i. Periodic visits (at least twice per year) for treatment by a health care provider or by a nurse under direct supervision of a health care provider; AND ii. Continues over an extended period of time, including recurring episodes of a single underlying condition; AND iii. May cause episodic rather than a continuing period of incapacity. Examples include asthma, diabetes, or epilepsy. iv. Absences due to a chronic condition still qualify for FMLA leave even though the employee or 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 3 consecutive full calendar days. For example, an employee with asthma may not be able to report to work due to the onset of an asthma attack or because the employee s health care provider has advised the employee to stay home whenever the pollen count exceeds a certain level. OR c. 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. OR d. 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, either for: i. Restorative surgery after an accident or other injury, or ii. For a condition that would likely result in a period of incapacity of more than 3 consecutive calendar days in the absence of medical intervention or treatment. Examples include cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), or kidney disease (dialysis). NOTE: An employee s serious health condition may also qualify under the federal Americans with Disabilities Act (ADA) and/or the California Fair Employment and Housing Act (FEHA), which may require that additional benefits be provided. Contra Costa County Page 10 of 31 Family & Medical Leave Handbook Rev. 4/2010

14 WHAT IS NOT A SERIOUS HEALTH CONDITION? Short term conditions requiring brief treatment such as the common cold, flu, earaches, upset stomach, minor ulcers, headaches (except migraines), routine dental problems and periodontal disease. Conditions for which cosmetic treatments are administered, such as plastic surgery or most treatments for acne, unless inpatient hospital care is required or complications arise. Conditions such as mental illness and allergies may be serious health conditions, but only if all the conditions discussed in the previous topic, What is a Serious Health Condition Entitling an Employee to FMLA Leave? are met. Substance abuse may be a serious health condition if the conditions discussed in the previous topic, What is a Serious Health Condition Entitling an Employee to FMLA Leave? are met. FMLA leave may only be taken for substance abuse treatment by a health care provider or by a provider of health care services on referral by a health care provider. Absence because of the employee s use of the substance, rather than treatment, does not qualify for FMLA leave. Contra Costa County Page 11 of 31 Family & Medical Leave Handbook Rev. 4/2010

15 HEALTH CARE PROVIDERS For purposes of the FMLA, the following is a list of approved health care providers: Doctor of medicine or osteopathy Podiatrist Dentist Clinical Psychologist Optometrist Chiropractor (limited to treatment consisting of manual manipulation of the spine) Nurse Practitioner Nurse-Midwife Clinical Social Worker Christian Science Practitioner listed with the First Church of Christ, Scientist of Boston, Massachusetts Physician Assistants Any Health Care Provider recognized by the County s group health plan A Health Care Provider as defined above who practices and is licensed in a country other than the U.S. Contra Costa County Page 12 of 31 Family & Medical Leave Handbook Rev. 4/2010

16 DESIGNATION OF LEAVE In all circumstances, it is the County s responsibility to designate leave as FMLA qualifying and to give notice of the designation to the employee. An employee is responsible for providing sufficient information to allow the County to determine his or her qualification for FMLA leave. An employee need not specifically refer to FMLA leave to meet his or her obligation for requesting FMLA leave. If an employee refuses or fails to provide requested medical certification, the County may deny FMLA leave until sufficient information is provided. If leave is not foreseeable, employees must give notice as soon as practicable. As soon as practicable means as soon as both possible and practical, taking into account all of the fact and circumstances in the individual case. If leave is foreseeable, the employee must give 30 calendar days advance notice of the need for leave. The department may retroactively designate leave as FMLA leave provided that it does not cause harm or injury to the employee. The department and the employee can mutually agree that leave be retroactively designated as FMLA leave. EMPLOYEE REPORTING REQUIREMENTS An employee on an approved intermittent or periodic FMLA leave shall provide at least verbal notice sufficient to make the department aware that the employee needs FMLA qualifying leave, and the anticipated timing and duration of the leave. When advance notice is not possible, it should be practicable for the employee to provide notice the same day or the next business day. If an employee is already approved for intermittent FMLA leave, the employee must notify the department if he or she wishes to convert the leave for this qualifying reason to an extended, non-intermittent FMLA leave. The employee is required to follow usual and customary notice and procedural requirements for requesting and reporting leave. They may be required to contact a specific individual to report the leave or follow similar required procedures. Contra Costa County Page 13 of 31 Family & Medical Leave Handbook Rev. 4/2010

17 REQUIRED NOTICES The department must provide the employee with the following notices pursuant to the FMLA: 1. General Notice Post the Employee Rights and Responsibilities under the Family and Medical Leave Act General Notice (Appendix A) in a conspicuous place in the workplace, such as a bulletin board where other legal notices are posted. Include a copy of the General Notice in any employee handbook or written guidance to employees concerning employee benefits or leave rights, if such written materials exist. Distribute a copy of the General Notice to each new employee upon hiring. Notice may be electronically posted or distributed. 2. Notice of Eligibility and Rights and Responsibilities (Eligibility Notice) Notify the employee of his or her eligibility and rights to take FMLA leave within 5 business days of learning that the request for leave is FMLA based. Eligibility Notice must be in writing, although the department may inform the employee verbally before sending the written notice. Departments are encouraged to use the sample Eligibility Notice at Appendix B. Eligibility Notice must be provided at the commencement of the first instance of leave for each FMLA qualifying reason in the 12-month period. All FMLA absences for the same qualifying reason are considered a single leave. No Eligibility Notice is required if the employee s eligibility status has not changed when an employee requests a subsequent leave for a different FMLA-qualifying reason in the same 12-month period. If eligibility status has changed, a new Eligibility Notice must be provided within 5 business days. Eligibility Notice must state whether the employee is eligible. If the employee is not eligible, the Notice must state at least one reason why the employee is not eligible, such as the number of months the employee has been employed or the number of hours of service worked during the 12-month period. The Eligibility Notice must also include, as appropriate, the following: o That the leave may be counted against the employee s annual FMLA leave entitlement if qualifying; o The applicable 12-month period for FMLA entitlement; Contra Costa County Page 14 of 31 Family & Medical Leave Handbook Rev. 4/2010

18 o Any requirements for the employee to furnish certification of a serious health condition, serious injury or illness, or qualifying exigency arising out of active duty or call to active duty status, and the consequences of failing to do so; o The employee s right to substitute paid leave, whether the department will require the substitution of paid leave, the conditions related to any substitution, and the employee s entitlement to take unpaid FMLA leave if the employee does not meet the conditions for paid leave; Note: Check applicable MOU as to whether the Department can require the use of accruals other than sick leave. o Any requirement for the employee to make premium payments to maintain health benefits, the arrangements for making such payments, and the possible consequences of failure to make such payments on a timely basis; o The employee s status as a key employee and the potential consequence that restoration to employment may be denied following FMLA leave, including the conditions required for such denial; Key Employee: means a salaried FMLA-eligible employee who is among the highest paid 10% of all the employees employed by the County determined at the time the employee gives notice of the need for leave. o The employee s rights to maintenance of benefits during the FMLA leave and restoration to the same or an equivalent job upon return from FMLA leave; o The employee s potential liability for payment of health insurance premiums paid by the County during the employee s unpaid FMLA leave if the employee fails to return to work after taking FMLA leave; It is good practice to send any required medical certification form with the Eligibility Notice. 3. Designation Notice Provide the Designation Notice to employee within 5 business days of when the department has enough information to determine whether the leave will be designated and counted as FMLA leave. The Notice must state the amount of leave counted against the employee s FMLA leave entitlement. A sample Designation Notice is at Appendix C. If the requested leave will not be designated as FMLA-qualifying, the department must notify the employee of that determination. Reasons for not designating leave as FMLA leave may be, for example, because the employee already exhausted the FMLA leave entitlement or the reason for the leave may not be covered by the FMLA. Contra Costa County Page 15 of 31 Family & Medical Leave Handbook Rev. 4/2010

19 The Designation Notice must inform the employee if paid leave will be substituted for unpaid FMLA leave or if leave taken under an existing leave plan will be counted as FMLA leave. The Designation Notice must inform the employee of any requirement for a fitness-for-duty certification to return to work. If the fitness-for-duty certification must address an employee s ability to perform the essential functions of the job, then the department must include such requirement in the Designation Notice and include a list of the essential functions of the employee s position with the Designation Notice. Only one Designation Notice is required for each FMLA-qualifying reason per applicable 12-month period. If the employee requests a subsequent leave and the information in the Designation Notice changes, the department must provide written notice of any changes within 5 business days of receipt of the employee s need for leave subsequent to any change. Send this Notice when the employee has exhausted the 12 or 18 weeks of leave. Contra Costa County Page 16 of 31 Family & Medical Leave Handbook Rev. 4/2010

20 WORKERS COMPENSATION If an eligible employee is on a workers compensation leave of absence for an injury or illness that also meets the criteria for a serious health condition under the FMLA, the department must also designate the leave as FMLA leave, which will run concurrently with the workers compensation absence. If an employee returns to a limited duty assignment and the limited duty is also a part-time schedule, the time not worked can be counted as FMLA. For example, an employee who normally works a 40-hour week, but only works 20 hours while on limited duty can have 20 hours of FMLA counted each week. For purposes of designating a workers compensation leave as FMLA leave, the department should coordinate with Risk Management to obtain the necessary medical certification in order to avoid employees having to obtain duplicate certifications. The department will still be responsible for sending out the required FMLA notices to the employee under these circumstances. Any questions about FMLA interaction with workers compensation should be directed to Risk Management. Contra Costa County Page 17 of 31 Family & Medical Leave Handbook Rev. 4/2010

21 MEDICAL CERTIFICATIONS The County may require that an employee s leave to care for the employee s seriously ill spouse, child, parent, or domestic partner, or due to the employee own serious health condition, be supported by a certification issued by the health care provider for the employee or the employee s ill family member. The request for medical certification should be made at the time the employee gives notice of the need for leave or within 5 business days after leave commences, if leave is unforeseen. California law does not permit employers to ask for a diagnosis in a medical certification. For that reason, do not use the federal medical certification form- it has a section asking for a medical diagnosis. Instead, use the California certification of health care provider form. An example is attached at Appendix D for certification of an employee s own serious health condition and Appendix E for certification of a family member s serious health condition. The employee is entitled to 15 calendar days to obtain medical certification; however, the County can preliminarily designate the time of as FMLA time before the medical certification is received. If the employee does not provide a requested medical certification, the request for leave can be denied and any time the employee has already taken off would not be protected FMLA leave. If the medical certification provided by the employee is defective, the employee has 7 calendar days to cure the defect. If the defect is not cured, then the leave may be denied until the employee provides a sufficient certification. Certification for leave to care for a family member shall contain: The date, if known, on which the serious health condition commenced; The probable duration of the condition; An estimate of the amount of time which the employee needs to render care or supervision; A statement that the serious health condition warrants the participation of a family member to provide care during the period of treatment or supervision; If for intermittent leave or reduced work schedule leave, the certification should indicate that the intermittent leave or reduced leave schedule is necessary for the care of the individual or will assist in their recovery, and its expected duration; An employee filing a claim with the Employment Development Department (EDD) to receive Paid Family Leave benefits must submit a medical certification to the EDD. It is important that the County still request a medical certification pursuant to the guidelines above, even if the employee is submitting a medical certification to the EDD. Certification for leave due to the employee s own serious health condition shall contain: Contra Costa County Page 18 of 31 Family & Medical Leave Handbook Rev. 4/2010

22 The date, if known, on which the serious health condition commenced; The probable duration of the condition; A statement that the employee is unable to perform the functions of the employee s job; If for intermittent leave or a reduced work schedule leave, the certification should indicate the medical necessity for the intermittent leave or reduced work schedule leave and its expected duration. An employee filing a claim with the Employment Development Department (EDD) to receive State Disability Insurance (SDI) benefits must submit a medical certification to the EDD. It is important that the County still request a medical certification pursuant to the guidelines above, even if the employee is submitting a medical certification to the EDD. NOTE: For an employee s own serious health condition, the County can ask for a second opinion by a health care provider chosen by the County (other than a County physician or physician the County has a contract with or regularly uses as a health care provider). A third opinion can be obtained from a jointly designated or approved health care provider. Under California law, the County IS NOT permitted to ask for a second opinion on the need for leave when the leave is to care for a family member. All medical information must be kept in a file separate from the employee s regular personnel file. ADA and FMLA medical information can be kept in the same medical file. Contra Costa County Page 19 of 31 Family & Medical Leave Handbook Rev. 4/2010

23 REQUESTING RECERTIFICATIONS The County may require the employee to obtain a recertification if additional leave is required to care for a family member or for an employee s own serious health condition upon expiration of the time estimated by the employee s or the family member s health care provider in the initial certification. The County may require recertification if it receives information that casts doubt upon the employee s stated reason for the absence or the continuing validity of the certification. Example #1: If an employee is on FMLA leave for 4 weeks for the employee s knee surgery and recuperation, and the employee plays in a department softball league game during the third week of the FMLA leave, such information might be sufficient to cast doubt upon the continuing validity of the certification allowing the County to request a recertification. Example #2: If an employee has a medical certification stating that the employee will need 4 hours of intermittent FMLA leave per week, and the employee claims 2 days of FMLA leave per week, the department can request a recertification. The employee must provide the requested recertification within 15 calendar days unless not practicable to do so under the circumstances. The employee must pay for the expense of the recertification. No second or third opinion may be required for purposes of recertification. Contra Costa County Page 20 of 31 Family & Medical Leave Handbook Rev. 4/2010

24 EMPLOYEE S INTENT TO RETURN TO WORK The County can require periodic reports from the employee of the employee s status and intent to return to work every 30 calendar days while on FMLA leave. The employee may be made of aware of this requirement in the Eligibility Notice that is sent when the leave commences. Prior to the date of the employee s return to work, the department should check-in with the employee to confirm the employee s intent to return to work on the stated date. A reminder letter a couple of weeks before the expiration of the leave is a good practice to implement. If the employee gives unequivocal notice of intent to return to work, obligations under the FMLA cease. The County may require 2 business days notice of the employee s intent to return to work early. Contra Costa County Page 21 of 31 Family & Medical Leave Handbook Rev. 4/2010

25 FITNESS FOR DUTY REPORTS An employee who takes leave can be required to obtain and present certification from the employee s health care provider that the employee is able to return to work. Restoration of employment may be delayed until an employee submits a required fitness for duty certification, unless the department failed to notify the employee of the fitness for duty requirement in the Designation Notice. The department must inform the employee in the Designation Notice that a fitness for duty certification will be required or the department cannot delay job restoration for failure to provide certification. If the department wants the fitness for duty certification to include whether the employee can perform the essential functions of the employee s job, then the department must provide the employee with a list of the employee s essential job functions with the Designation Notice. The department must also indicate in the Designation Notice that such a determination must be included by the health care provider in the fitness for duty certification. A fitness for duty certification may only be required if there is a uniformly applied policy or practice that requires all similarly situated employees (same occupation, same serious health condition) who take leave to submit a certification prior to returning to work. The department may contact the employee s health care provider only to clarify specific items on the certification form and to authenticate the fitness for duty certification. The department may not delay the employee s return to work while contact with the health care provider is being made. However, if the department required a fitness for duty certification on the Designation Notice and the employee does not submit it, then the department may delay the return to work until it is submitted. There are no second or third opinions on fitness for duty certifications. The department may not require a fitness for duty certification for each absence taken on an intermittent or reduced leave schedule. Contra Costa County Page 22 of 31 Family & Medical Leave Handbook Rev. 4/2010

26 USE OF ACCRUALS FMLA leave is unpaid. However, the FMLA permits an employee to choose to use paid leave (sick leave, vacation, management leave, floating holiday and compensatory time) while on an FMLA leave. The department may require the employee to use accruals during an FMLA leave. Check the applicable MOU to determine whether the department can require the use of accruals other than sick leave. The type of leave and the conditions under which it will be used must be indicated in the Eligibility Notice and in the Designation Notice. If neither the employee nor the department elects to substitute paid leave for unpaid leave, the employee remains entitled to all the accruals under the terms of the County s plan. Use of sick leave accruals may be elected to the extent the circumstances meet the County s usual requirements for the use of sick leave accruals. The County is not required to allow the use of sick leave accruals during an FMLA leave in any situation where the County s uniform policy does not normally allow such paid leave. Example: The County s sick leave policy does not allow sick leave accruals to be used during an FMLA/CFRA leave for baby bonding because sick leave accruals are for use during temporary absences from work due to illness or injury. A leave for baby bonding does not involve illness or injury. Refer to Administrative Bulletin No and the applicable MOU for sick leave policies. Contra Costa County Page 23 of 31 Family & Medical Leave Handbook Rev. 4/2010

27 MAINTENANCE OF BENEFITS Health Plans: The County must maintain the employee s group health insurance coverage for the duration of the qualified FMLA leave at the level and under the conditions that the coverage would have been provided if the employee were not on leave. The employee is required to pay the full employee contribution to maintain his/her group health plan coverage, either through payroll deduction or by paying the County Auditor directly, via check, by the 10 th of the month. If the employee fails to make payments, the County can cancel coverage provided the County allows the employee a 30 day grace period to pay and provide written notice of intent to cancel at least 15 days before coverage is lost. The employee can choose not to continue health insurance during FMLA leave. If health coverage is lost (waived or canceled) during the FMLA leave, when the employee returns to work the coverage must be reinstated. The employee is not required to pay back premiums and no preexisting condition limitations or waiting period may be imposed when coverage is reinstated. Pension and Retirement Plans: FMLA leave must be treated as regular continued service (no service breaks) for the purposes of vesting and eligibility to participate in pension and retirement plans. Seniority: FMLA leave does not impact an employee s seniority. Contra Costa County Page 24 of 31 Family & Medical Leave Handbook Rev. 4/2010

28 REINSTATEMENT FROM FMLA LEAVE An employee must be reinstated to the same or equivalent position at the conclusion of his/her designated and approved FMLA leave. The position must be equivalent in terms of pay, benefits, and working conditions. The employee must be reinstated to the same or a geographically proximate worksite (i.e., one that does not involve a significant increase in commuting time or distance). The employee ordinarily is entitled to return to the same shift or the same or an equivalent work schedule. An employee is entitled to a position with the same or equivalent pay premiums, such as shift differential or overtime. DENYING JOB RESTORATION An employee has no greater right to reinstatement than if the employee had been continuously employed. For example, if the employee is laid off during the course of taking FMLA leave, the County s responsibility to continue FMLA leave, maintain group health benefits and reinstate the employee ceases at the time the employee is laid off, unless otherwise provided under an MOU or policy. If upon an employee s return to work the Department believes that it will be necessary to deny job restoration, the Department should contact the Labor Relations Department or County Counsel for assistance, and the County s ADA Coordinator to determine if the employee has further rights under the Americans with Disabilities Act. Contra Costa County Page 25 of 31 Family & Medical Leave Handbook Rev. 4/2010

29 LEAVES RELATED TO PREGNANCY, CHILDBIRTH, & BABY-BONDING Pregnancy Disability Leave (PDL): Leave for the period of time when a woman is temporarily disabled by pregnancy. A woman is disabled due to pregnancy if, in the opinion of her health care provider, she is unable to work at all or is unable to perform any one or all of the essential functions of her job or to perform these functions without undue risk to herself, the successful completion of her pregnancy, or to other persons. A woman is also considered disabled by pregnancy if she is suffering severe morning sickness or needs to take time off for prenatal care. Employees are entitled to up to 4 months of PDL. PDL is time off only. It does not guarantee pay or benefits. Employees may use accruals to receive pay and benefits during PDL. Where there are no complications, health care providers usually apply State Disability Insurance (SDI) criteria and presume that an employee is disabled due to her pregnancy for a period up to 4 weeks prior to the birth and for a period of 6 weeks following the birth (8 weeks following a Caesarian section). If the employer provides more than four months of leave for other temporary disabilities, the same leave must also be made available to women who are disabled due to pregnancy, childbirth, or a related medical condition. The length of time that an employee is actually disabled due to her pregnancy is determined by her health care provider and can exceed the SDI guidelines above. The department can require medical certification for a pregnancyrelated disability leave. The department does not have the right to challenge the employee s physician in the case of pregnancy-related leave. There is no length of service requirement for an employee who is pregnant to be eligible for PDL. In Contra Costa County, leave from work due to pregnancy disability may NOT run concurrently with CFRA or County family care leave under the PMRs or MOUs. FMLA may run concurrently with pregnancy disability leave. CFRA Baby-Bonding Leave: For employees on PDL, CFRA leave does not begin until after the employee is no longer disabled by pregnancy. Contra Costa County Page 26 of 31 Family & Medical Leave Handbook Rev. 4/2010

30 Eligibility for baby-bonding leave ends 12 months after the child s birth or placement of the child through adoption or foster care. For spouses or domestic partners, CFRA leave begins at childbirth. FMLA leave may also be used prior to child birth, such as to care for a woman suffering from severe morning sickness or to accompany her to medical appointments for prenatal care. Refer to the County s sick leave policy and applicable MOUs for use of sick leave accruals during an FMLA/CFRA leave for baby bonding. Where the parents (whether married or not) of a child are both employed by the County, CFRA leave based on the birth, adoption, or foster care of a child is limited to an aggregate for both employees together of 12 or 18 weeks during a rolling 12-month period measured backward from the date an employee uses his/her CFRA leave. Employees represented by the Deputy Sheriffs Association are not required to aggregate any of their 12 week leave entitlement. The Employee s Own Serious Health Condition: Under the CFRA, an employee who is disabled on account of pregnancy, childbirth, or related medical conditions does not have a serious health condition. Under the FMLA, an employee who is receiving continuing treating by a health care provider for prenatal care or during any period of incapacity due to pregnancy has a serious health condition. Reinstatement from Pregnancy Disability Leave: If an employee returns to work at the end of her PDL and does not continue with CFRA baby-bonding leave, the employee is entitled to reinstatement to the same position she occupied prior to her PDL. Reinstatement to a comparable position in this situation is only permitted if the department proves beyond a preponderance of the evidence that either: 1) The employee would not otherwise have been employed in her same position at the time reinstatement is requested for legitimate business reasons unrelated to the employee taking a PDL or transfer (such as a layoff); OR 2) The means of preserving the job or duties for the employee (such as leaving it unfilled or filling it with a temporary employee) would substantially undermine the department s ability to operate safely and efficiently. If the employee remains out on a CFRA baby-bonding leave at the end of her PDL, then the general reinstatement requirements under the FMLA/CFRA apply. Contra Costa County Page 27 of 31 Family & Medical Leave Handbook Rev. 4/2010

31 Lactation Accommodation: Federal law and California Labor Code section 1030 require employers to provide a reasonable amount of break time to accommodate an employee who wishes to express breast milk for the employee s infant. Departments should make reasonable efforts to provide the employee with a room or other location, other than a toilet stall, in close proximity to the employee s work area, for the employee to express milk in private. The room or location may include the place where the employee normally works if it satisfies the privacy requirements, such as a private office with a door. Departments are encouraged to provide the pamphlet at Appendix G to all pregnant employees for their information. Contra Costa County Page 28 of 31 Family & Medical Leave Handbook Rev. 4/2010

32 PAID FAMILY LEAVE In 2002, Senate Bill 1661 extended disability compensation to employee who take time off work to care for a seriously ill child, spouse, parent, domestic partner, or to bond with a child following birth, adoption or foster care placement of a child. This program, which began on July 1, 2004, is know as Paid Family Leave and is administered by the State Employment Development Department s (EDD) Disability Insurance Branch. Coverage and Benefits Employees must take Paid Family Leave concurrent with FMLA and CFRA-eligible leaves. This benefit does not extend the 18 weeks of FMLA leave to which most County employees are currently entitled. Paid Family Leave is a misleading name. It is a component of the State Disability Insurance (SDI) program and is a wage replacement program only. It does not entitle employees to additional time off. Employees in the County who are not currently covered by SDI (i.e., employees not employed in a classification eligible for SDI and not making SDI contributions) are not eligible to receive this benefit. Employees should contact EDD for information on the amount of the weekly benefits they are entitled to under this program. No more than 6 weeks of Paid Family Leave benefits may be paid within any 12 month period. A 12 month period under Paid Family Leave is defined as 365 consecutive days beginning with the first day from which the individual first establishes a valid claim for Paid Family Leave benefits. Eligibility Requirements Unlike FMLA, an employee is not required to work a minimum number of hours or for a specific time period with the County before becoming eligible for Paid Family Leave. Therefore, an employee may be eligible to take Paid Family Leave, but may not be eligible for FMLA leave. Employee must file claims for Paid Family Leave benefits directly with EDD. Paid Family Leave may be requested for the following reasons: To care for a seriously ill child, spouse, parent or domestic partner; To bond with a new child after the birth of a child of the individual or the individual s registered domestic partner; or To bond with a minor child in connection with the adoption or foster care placement of a child with the individual or the individual s registered domestic partner. An employee cannot file a claim for Paid Family Leave benefits in connection with the employee s own serious health condition. A medical certification is required when a Paid Family Leave claim is filed to provide care for a seriously ill family member. The employee will be required to submit the medical certification to the EDD. A Paid Family Contra Costa County Page 29 of 31 Family & Medical Leave Handbook Rev. 4/2010

33 Leave and FMLA/CFRA run concurrently, it is important that the Department request a copy of the medical certification for the FMLA/CFRA portion of the leave. For baby-bonding leave, Paid Family Leave is limited to the first year after the birth, adoption, or foster care placement of a child. Employees will be required to submit a certificate to the EDD for a leave associated with the birth, adoption, or foster care placement of a child. There is a 7 calendar day waiting period before benefits are paid by the EDD. In addition, the County will require an employee to use up to 2 weeks of earned but unused vacation leave prior to receiving benefits from the EDD, one week of which will be considered the 7 day waiting period. Employees cannot receive Paid Family Leave while receiving SDI, Unemployment Insurance, or Workers Compensation benefits. Claim Form and Informational Brochure Employees can obtain a Paid Family Leave benefit claim form by contacting EDD at BE-THERE or at An informational brochure must be provided to each employee requesting leave for a sick or injured family member or to bond with a new child. A copy of this brochure is included in Appendix F. Additional copies can be obtained at the EDD website. Contra Costa County Page 30 of 31 Family & Medical Leave Handbook Rev. 4/2010

34 LEAVE CHECKLIST Leave request received or learned of need for leave Eligibility Notice sent (no later than 5 business days after leave request) EDD s Paid Family Leave Brochure sent along with Eligibility Notice if requested leave is to care for family member or for baby bonding SDI Pamphlet DE 2515 sent along with Eligibility Notice if requested leave is for the employee s non-industrial medical condition Medical Certification received from employee (within 15 calendar days of leave request) Defective Medical Certification cured (within 7 calendar days of notice of defect) Designation Notice sent (no later than 5 business days of receipt of sufficient information to determine whether to designate leave as FMLA leave) Medical Recertification requested from employee who needs leave beyond initial medical certification Medical Recertification received from employee (within 15 calendar days of department request for recertification) Contacted employee to confirm return-to-work date (a couple of weeks before return date on medical certification) Sent Letter confirming/reminding employee of return-to-work date Designation Notice sent when amount of eligible leave is exhausted Fitness for Duty certification received from employee Employee returns to work File all medical documentation in a separate file, not in the employee s personnel file Contra Costa County Page 31 of 31 Family & Medical Leave Handbook Rev. 4/2010

35 APPENDIX A

36 Basic Leave Entitlement FMLA requires covered employers to provide up to 12 weeks of unpaid, jobprotected leave to eligible employees for the following reasons: For incapacity due to pregnancy, prenatal medical care or child birth; To care for the employee s child after birth, or placement for adoption or foster care; To care for the employee s spouse, son or daughter, or parent, who has a serious health condition; or For a serious health condition that makes the employee unable to perform the employee s job. Military Family Leave Entitlements Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered servicemember during a single 12-month period. A covered servicemember is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the servicemember medically unfit to perform his or her duties for which the servicemember is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary disability retired list. Benefits and Protections During FMLA leave, the employer must maintain the employee s health coverage under any group health plan on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee s leave. Eligibility Requirements Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 50 employees are employed by the employer within 75 miles. Definition of Serious Health Condition A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee s job, or prevents the qualified family member from participating in school or other daily activities. Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment. EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER THE FAMILY AND MEDICAL LEAVE ACT Use of Leave An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis. Substitution of Paid Leave for Unpaid Leave Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer s normal paid leave policies. Employee Responsibilities Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer s normal call-in procedures. Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave. Employer Responsibilities Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility. Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee s leave entitlement. If the employer determines that the leave is not FMLAprotected, the employer must notify the employee. Unlawful Acts by Employers FMLA makes it unlawful for any employer to: Interfere with, restrain, or deny the exercise of any right provided under FMLA; Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA. Enforcement An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights. FMLA section 109 (29 U.S.C. 2619) requires FMLA covered employers to post the text of this notice. Regulations 29 C.F.R (a) may require additional disclosures. For additional information: US-WAGE ( ) TTY: U.S. Department of Labor Employment Standards Administration Wage and Hour Division WHD Publication 1420 Revised January 2009

37 APPENDIX B

38 Notice of Eligibility and Rights and Responsibilities Family and Medical Leave Act Contra Costa County Date: To: From: * Please note only fields marked are applicable PART A NOTICE OF ELIGIBILITY On FMLA. you informed us or we learned that you needed leave which possibly qualifies under the The birth of a child or placement of a child with you for adoption or foster care Your own serious health condition Because you are needed to care for your spouse child parent due to his//her serious health condition. Because of a qualifying exigency arising out of the fact that your spouse son or daughter parent is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves. Because you are the spouse son or daughter parent next of kin of a covered servicemember with a serious injury or illness.

39 Page 2 This notice is to inform you that: You meet the basic eligibility requirements for FMLA. See part B for further instructions. You are not eligible for FMLA leave, because of the following reason(s) You have not met the FMLA length of service requirement. As of the first date of requested leave, you have worked approximately months toward this requirement. You may be entitled once you have reached the 12 month mark. You have not met the 1,250 hours worked requirement. You may be eligible once you have worked the required 1,250 hours. We have not received the completed certification form within the time allotted. Other: PART B - RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE As explained in Part A, you meet the initial eligibility requirement for taking FMLA leave and still have FMLA leave available in the applicable 12 month period. Additional information is needed to determine if you qualify: In order for us to determine whether your absence qualifies as FMLA leave, you must return the information listed below to us by You will be allowed 15 calendar days from receipt of this notice; additional time may be allowed in some circumstances. If sufficient information is not provided in a timely manner, your leave may be denied. Sufficient certification to support your request for FMLA leave. A 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. Other information needed: NO ADDITIONAL INFORMATION IS NEEDED. SEE RESPONSIBILITY REQUIREMENTS BELOW AS WELL AS THE DESIGNATION NOTICE.

40 Page 3 RESPONSIBILITIES: If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA (only check boxes which apply). Contact County Auditors office at to make arrangement to continue to make your share of the health premium payments if you wish to maintain health benefits while you are on leave. You have a minimum 30 day grace period in which to make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided the County notifies you in writing at least 15 days before the date your health coverage will lapse. You will be required to use : your available paid sick vacation other leave during your FMLA absence. This means that you will receive your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave entitlement While on leave you will be required to furnish us with periodic reports of your status and intent to return to work every or prior to the expiration of your medical certification. If the circumstances of your leave change and you are able to return to work earlier than the date originally indicated, you will be required to notify us at least two workdays prior to the date you intend to report for work. RIGHTS: If your leave qualifies as FMLA leave you will have the following rights while on FMLA leave: You have a right under the FMLA for up to 12 weeks 18 weeks of unpaid leave in a 12 month period calculated as a rolling 12 month period measure backward from the date of any FMLA leave 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 servicemember with a serious injury or illness This single 12 month period commenced on. Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work. You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on 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.

41 Page 4 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 servicemember s serious injury or illness which would entitle your to FMLA leave; 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. If we have not informed you above that you must use accruals while taking your unpaid FMLA leave entitlement, you have the right to have sick vacation and/or other leave 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 set forth in the County s PMR and MOU s. If you do not meet the requirements for taking paid leave, you remain entitled to take unpaid FMLA leave. You may be entitled to partial wage replacement through the State of California's Disability Insurance Program. Enclosed is the State of California s informational pamphlet regarding Disability Insurance Provisions. If you have permanent employment status with Contra Costa County and pay into State Disability Insurance, you should contact Human Resources/Benefits and explore your options under the County s SDI buy back program. IF ADDITIONAL INFORMATION WAS REQUESTED AS SPECIFIED ABOVE, WE WILL INFORM YOU WITHIN 5 BUSINESS DAYS FROM RECEIPT OF THE INFORMATION, WHETHER YOUR LEAVE WILL BE DESIGNATED AS FMLA LEAVE AND COUNT TOWARDS YOUR FMLA LEAVE. If you have any questions, please contact at Please return completed certification form to: cc:

42 APPENDIX C

43 Designation Notice Family and Medical Leave Act Contra Costa County Date: To: From: We have reviewed recent medical information regarding its applicability to leave under the FMLA. SECTION I: * Please note only fields marked are applicable You are approved for FMLA leave. All leave taken for this reason will be designated as FMLA leave. Your leave under FMLA leave begins effective. The FMLA requires that you notify us as soon a practicable if dates of scheduled leave change or are extended, or were initially unknown. You are required to advise your department verbally and indicate on your time sheet any hours or days taken for this designated FMLA leave. Based on the information you have provided to date, we are providing the following information about the amount of time that will be counted against your leave entitlement: Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will or have been counted against your leave entitlement:

44 Page 2 At this point in time, we are unable to determine the exact period(s) of your leave. Therefore, it is not possible to provide the hours, days, or weeks that will be counted against your FMLA entitlement at this time. It is therefore imperative you designate FMLA time off on your time sheet. You have the right to request an accounting of your FMLA usage once in a 30 day period (if leave was taken in the 30 day period). Pay Status while on leave: You have requested to use paid leave during your FMLA leave. Any paid leave taken for this reason will count against your FMLA leave entitlement. You have requested to use sick leave vacation other. We are requiring you to use accruals during your FMLA leave sick leave vacation other. Return to work: You will be required to present a fitness for duty certificate to be restored to employment. If such certification is not timely received, your return to work may be delayed until the certification is provided. A list of the essential functions of your position is is not attached. If it is attached, the fitness for duty certification must address your ability to perform these functions and outline any limitations you might have. SECTION II: Additional information is needed to determine if your FMLA request can be approved: The certification you have provided is not complete and sufficient to determine whether the FMLA applies to your leave request. You must provide the following information within 7 calendar days from the date of this notice unless it is not practicable under the particular circumstances despite your diligent good faith efforts, or your leave may be denied. We may also elect to contact your provider directly if we do not receive the necessary information as listed below. This contact would only be made by your departmental personnel staff.

45 The following information needs to be provided: Page 3 We are exercising our right to have you obtain a second or third opinion medical certification at our expense, and we will provide further details at a later time. SECTION III: Your FMLA leave request is not approved for the following reason: You have exhausted your FMLA leave entitlement in the applicable 12 month period FMLA does not apply to your leave request for the following reason: Other If you having any questions, you may contact at SECTION IV: You also are approved for leave under the California Family Rights Act (CFRA) and County Family Care and Medical Leave. Such leave will run concurrently with the FMLA leave described above. Please return completed certification form to: cc:

46 APPENDIX D

47 Certification of Health Care Provider for Contra Employee s Serious Health Condition Costa Family and Medical Leave Act County Section I: For Completion by the Employer: Instructions to the Employer: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee to submit a medical certification issued by the employee s health care provider prior to designating FMLA leave. Please complete Section I before giving the form to the employee. While you are not required to use this form, you may not ask the employee to provide more information than is allowed under the FMLA regulations, 29CFR Employers must maintain records and documents relating to medical certification, recertification, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/ records from the usual personnel files and in accordance with 29 CFR (c)(1), if the Americans with Disabilities Act applies. Employer name and Contact: Employee s job title: Regular work schedule: Employee s essential job functions: Section II: For Completion by the Employee: Instructions for the Employee: Please complete Section II before giving this form to your medical provider. An employer may require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. You have 15 calendar days to return the completed form. If the returned form is not complete or sufficient, you will be given both verbal and written notice of the deficiency. You will then be given 7 calendar days to obtain the necessary information from your provider. If there is still inadequate information provided or a need for clarification, a staff member from you department s personnel unit will contact your doctor. Your name (print) First Middle Last

48 Certification for Employee s Own Health Condition Page 2 Section III: For Completion by the Health Care Provider Instruction to the Health Care Provider: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answers should be your best estimate based upon your medical knowledge, experience and examination of the patient. Be as specific as you can: terms such as lifetime, unknown, or Indeterminate may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking covered leave. Please be sure to sign the form on the last page. Provider s name and business address: PRINT Type of practice/medical specialty: Telephone: Fax Part A: Medical Facts 1. Approximate date condition commenced: 2. Probable duration of condition: 3. Was the employee admitted for an overnight stay in a hospital, hospice or residential medical care facility: No Yes, If so, dates of admission 4. Date(s) you treated the patient for this condition: If you have only seen the patient once, when will you see him/her again? 5. Was medication, other than over-the counter medication prescribed? No Yes 6. Was the patient referred to other health care providers for further evaluation or treatment? No Yes If so, state the expected duration of the treatment 7. Is the medical condition pregnancy? No Yes. If so, expected delivery date:

49 Certification for Employee s Own Health Condition Page 3 Ability to perform the essential functions of the employee s regular position: Use the information provided by the employer to answer this question. If the employer fails to provide a list of the employee s essential functions or a job description, answer these questions based upon the employee s own description of his/her job functions. 8. Is the employee unable to perform any of his/her job functions due to the condition? No Yes If so, identify the job functions the employee is unable to perform (additional space available on last page of this form) : PART B: AMOUNT OF LEAVE NEEDED 9. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition including any time for treatment and recovery? No Yes If so, estimate the beginning and ending dates for the period of incapacity: 10. Will the employee need to attend follow-up treatment appointments? Yes No Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: 11. Will the employee need to work part-time or on a reduced schedule because of his/her medical condition? Yes No Estimate the part-time or reduced work schedule the employee needs, if any: hours per day: days per week from (date) through 12. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? Yes No 13. Is it medically necessary for the employee to be absent from work during the flareups? No Yes. If so, explain:

50 Certification for Employee s Own Health Condition Page Based upon the patient s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity the patient may have over the next 6 months, e.g. 1 episode every 3 months lasting 1-2 days. Frequency: times per week(s) month(s) Duration: hours or day(s) per episode. ADDITIONAL INFORMATION: Provide additional information below. Identify question number, if applicable Signature of Health Care Provider Date

51 APPENDIX E

52 Certification of Health Care Provider for Contra Family Member s Serious Health Condition Costa Family and Medical Leave Act County Section I: For Completion by the Employer: Instructions to the Employer: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee to submit a medical certification issued by the covered family member s health care provider prior to designating FMLA leave. Please complete Section I before giving the form to the employee. While you are not required to use this form, you may not ask the employee to provide more information than is allowed under the FMLA regulations, 29CFR Employers must maintain records and documents relating to medical certification, recertification, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/ records from the usual personnel files and in accordance with 29 CFR (c)(1), if the Americans with Disabilities Act applies. Employer name and Contact: Employee s job title: Regular work schedule: Employee s essential job functions: Section II: For Completion by the Employee Instructions for the Employee: Please complete Section II before giving this form to your medical provider. An employer may require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. You have 15 calendar days to return the completed form. If the returned form is not complete or sufficient, you will be given both verbal and written notice of the deficiency. You will then be given 7 calendar days to obtain the necessary information from your provider. If there is still inadequate information provided or a need for clarification, a staff member from you department s personnel unit will contact your doctor. Your name (print) First Middle Last Name of family member for whom you will provide care (print): _ First Middle Last

53 Certification for Employee s Family Member s Serious Health Condition Page 2 Relationship of family member to you: If family member is your son or daughter, date of birth: Describe care you will provide to your family member and estimate leave needed to provide care: Employee Signature Date Section III: For Completion by the Health Care Provider Instruction to the Health Care Provider: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience and examination of the patient. Be as specific as you can: terms such as lifetime, unknown, or Indeterminate may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking covered leave. Please be sure to sign the form on the last page. Provider s name and business address: PRINT Type of practice/medical specialty: Telephone: Fax Part A: Medical Facts 1. Approximate date condition commenced 2. Probable duration of condition:

54 Certification for Employee s Family Member s Serious Health Condition Page 3 3. Was the patient admitted for an overnight stay in a hospital, hospice or residential medical care facility? No Yes, if so, dates of admission 4. Date(s) you treated the patient for this condition: 5. Was medication, other than over-the counter medication, prescribed? No Yes 6. Was the patient referred for further evaluation or treatment? No Yes If so, state the expected duration of the treatment. PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care: 7. Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? No Yes If so, estimate the beginning and ending dates for the period of incapacity: from through During this time will the patient need care? No Yes Explain the care needed by the patient and why such care is medically necessary: 8. Will the patient need to attend follow-up treatment appointments? Yes No Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

55 Certification for Employee s Family Member s Serious Health Condition Page 4 Explain the care needed by the patient, and why such care is medically necessary. 9. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? Yes No Estimate the hours the patient needs care on an intermittent basis, if any: hours per day day(s) per week from through Explain the care needed by the patient, and why such care is medically necessary. 10. Will the condition cause episodic flare-up periodically preventing the patient from participating in normal daily activities? No Yes Based upon the patient s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g. 1 episode every 3 months lasting 1-2 days) Frequency: times per week(s) months Duration: hours or day(s) per episode Does the patient need care during these flare-ups? No Yes. Explain the care needed by the patient, and why such care is medically necessary:

56 Certification for Employee s Family Member s Serious Health Condition Page 5 ADDITIONAL INFORMATION: Provide additional information below. Identify question number, if applicable Signature of Health Care Provider Date

57 APPENDIX F

58 STATE OF CALIFORNIA State and Consumer Services Agency DEPARTMENT OF FAIR EMPLOYMENT & HOUSING 2218 Kausen Drive, Suite 100 Elk Grove, CA Arnold Schwarzenegger, Governor "NOTICE A" PREGNANCY DISABILITY LEAVE Under the California Fair Employment and Housing Act (FEHA), if you are disabled by pregnancy, childbirth or related medical conditions, you are eligible to take a pregnancy disability leave (PDL). If you are affected by pregnancy or a related medical condition, you are also eligible to transfer to a less strenuous or hazardous position or to less strenuous or hazardous duties, if this transfer is medically advisable. You are also eligible to receive reasonable accommodation for conditions related to pregnancy, childbirth, or related medical conditions if you request it with the advice of your health care provider. The PDL is for any period(s) of actual disability caused by your pregnancy, childbirth or related medical conditions up to four months (or 88 work days for a full-time employee) per pregnancy. The PDL does not need to be taken in one continuous period of time but can be taken on an as-needed basis. Time off needed for prenatal care, severe morning sickness, doctor-ordered bed rest, childbirth, and recovery from childbirth would all be covered by your PDL. Generally, we are required to treat your pregnancy disability the same as we treat other disabilities of similarly situated employees. This affects whether your leave will be paid or unpaid. You may be required to obtain a certification from your health care provider of your pregnancy disability or the medical advisability for a transfer or reasonable accommodation. The certification should include: 1) the date on which you become disabled due to pregnancy or the date of the medical advisability for the transfer or reasonable accommodation; 2) the probable duration of the period(s) of disability or the period(s) for the advisability of the transfer or reasonable accommodation; and, 3) a statement that, due to the disability, you are unable to work at all or to perform any one or more of the essential functions of your position without undue risk to yourself, the successful completion of your pregnancy or to other persons or a statement that, due to your pregnancy, the transfer or reasonable accommodation is medically advisable. At your option, you can use any accrued vacation or other accrued time off as part of your pregnancy disability leave before taking the remainder of your leave as an unpaid leave. We may require that you use up any available sick leave during your leave. You may also be eligible for state disability insurance for the unpaid portion of your leave. Taking a pregnancy disability leave may impact certain of your benefits and your seniority date. If you want more information regarding your eligibility for a leave, the impact of the leave on your seniority and benefits, and our policy for other disabilities, please contact Employer s Contact Person at Employer's Telephone Number DFEH (01/00)

59

60 Paid Family Leave Insurance Program Paid Family Leave insurance benefits for California workers There are times in the life of every working person when they need to care for a loved one. Maybe it s a working parent who needs more time to bond with and care for a newborn. Maybe it s an employee who needs to care for a seriously ill parent, child, spouse, or registered domestic partner. California s Paid Family Leave insurance benefit was created for times like these. (Note: Registered domestic partners must meet requirements and register with the California Secretary of State to be eligible for benefits.) A program that benefits you and your family California is leading the nation as the first state to make it easier for employees to balance the demands of the workplace and family care needs at home. Paid Family Leave insurance benefits are based on the claimant's (care provider's) past quarterly earnings. For more information regarding maximum benefit amounts paid, view the link to the Disability Insurance (DI) & Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments form, DE 2589, at Paid Family Leave for California employees Paid Family Leave insurance does not provide job protection or return rights. Your job may be protected if your employer is subject to the federal Family Medical Leave Act and the California Family Rights Act. You must notify your employer of your reason for taking leave in a manner consistent with your company s leave policy. To qualify for Paid Family Leave compensation, you must meet the following requirements: Be covered by State Disability Insurance (SDI) (or a voluntary plan in lieu of SDI) and have earned at least $300 in your base period from which deductions were withheld. Complete your claim forms accurately, completely, truthfully, and timely. Submit your claim no earlier than 9 days, but no later than 49 days after the first day your family care leave began. Supply medical information that supports your claim that the care recipient has a serious health condition and requires your care. Provide documentation to support a claim for bonding with a new biological, adopted, or foster child. Use up to two weeks of any earned but unused vacation leave or paid time off (PTO) prior to the initial receipt of benefits if required by your employer prior to the initial receipt of benefits. Serve a 7-day unpaid waiting period before benefits begin for each different care recipient within the 12-month period. You may not be eligible for benefits if: You receive State Disability Insurance, Unemployment Insurance, or Workers Compensation. You are not working or looking for work at the time you begin your family care leave. You are not suffering a loss of wages. The need for care is not supported by the certificate of a treating physician or practitioner. You are in custody due to conviction of a crime. You are entitled to: Know the reason and basis for any decision that affects your benefits. Appeal any decision about your eligibility for benefits. (Appeals must be sent to Paid Family Leave in writing.) A hearing of your appeal before an Administrative Law Judge (ALJ). You may further appeal the ALJ's decision to the California Unemployment Insurance Appeals Board and the courts. Privacy Information about your claim will be kept confidential except for the purposes allowed by law. Fast facts about Paid Family Leave Provides benefits but does not provide job protection or return rights. Provides eligible workers partial wage replacement when taking time off work to care for parents, children, spouses, and registered domestic partners or to bond with a new minor child. Covers all employees who are covered by SDI (or a voluntary plan in lieu of SDI). Offers up to 6 weeks of benefits in a 12-month period. Provides benefits of approximately 55 percent of lost wages. Contact Paid Family Leave If you have any questions about these benefits or would like to request a claim form, contact us today. If you are a woman currently receiving SDI pregnancy-related benefits, it is not necessary to request a Claim for Paid Family Leave Benefits. You will automatically be sent a Claim for Paid Family Leave (PFL) Benefits - New Mother, DE 2501FP, when your preganancy-related disability claim ends (English) (Español) (Cantonese) (Vietnamese) (Armenian) (Punjabi) (Tagalog) (TTY) For more information, visit: Claim forms should be mailed to Paid Family Leave at: P.O. Box Sacramento, CA EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling (voice), or TTY This pamphlet is for general information only and does not have the force and effect of law, rule or regulation. DE 2511 I Rev. 5 (1-09) (INTERNET) Page 1 of 1

61 Notice to Employees: UI THIS EMPLOYER IS REGISTERED UNDER THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE AND IS REPORTING WAGE CREDITS THAT ARE BEING ACCUMULATED FOR YOU TO BE USED AS A BASIS FOR: Unemployment Insurance (funded entirely by employers taxes) When you are unemployed or working less than full-time and are ready, willing, and able to work, you may be eligible to receive Unemployment Insurance benefi ts. There are three ways to fi le a claim: Internet File on-line with eapply4ui the fast, easy way to fi le a UI claim! Access eapply4ui at Telephone File by contacting a customer service representative at one of the toll-free numbers listed below: English Spanish Cantonese Vietnamese Mandarin TTY (non voice) Mail or Fax File by mailing or faxing a UI Application (DE 1101I), by accessing the paper application on-line at Print out the application, hand write your answers, and mail or fax it to EDD for processing. DI PFL Note: File promptly. If you delay in fi ling, you may lose benefi ts to which you would otherwise be entitled. Disability Insurance (funded entirely by employees contributions) When you are unable to work or reduce your work hours because of sickness, injury, or pregnancy, you may be eligible to receive Disability Insurance (DI) benefi ts. Your employer must provide a copy of Disability Insurance Provisions, DE 2515, to each newly hired employee and to each employee leaving work due to pregnancy or due to sickness or injury that is not related to his/her job. Claim Forms If your employer operates an approved voluntary plan in place of disability insurance and you have chosen to be covered by it, obtain DI claim forms from your employer. If you are not covered by a voluntary plan, obtain claim forms from your doctor, hospital, or directly from any California Disability Insurance (DI) Claim Management offices. File your Claim for DI Benefits, DE 2501, within 49 days of the first day of your disability to avoid losing benefits. FOR MORE INFORMATION ABOUT DI, VISIT THE EDD WEB SITE AT OR CONTACT THE DISABILITY INSURANCE CUSTOMER SERVICE CENTER AT STATE GOVERNMENT EMPLOYEES SHOULD CALL TTY (FOR DEAF OR HEARING-IMPAIRED INDIVIDUALS ONLY) IS AVAILABLE AT Paid Family Leave (funded entirely by employees contributions) When you stop working or reduce your work hours to care for a family member who is seriously ill or to bond with a new child, you may be eligible to receive Paid Family Leave (PFL) benefits. Your employer must provide a copy of Paid Family Leave Program Brochure, DE 2511, to each newly hired employee and to each employee leaving work to care for a seriously ill family member or to bond with a new child. Claim Forms If your employer operates an approved voluntary plan in place of disability insurance and you have chosen to be covered by it, obtain PFL claim forms from your employer. If you are not covered by a voluntary plan, obtain claim forms from doctors, hospitals, or directly from any California Disability Insurance (DI) Claim Management offices or the PFL office. File your Claim for PFL Benefits, DE 2501F, within 49 days of the first day of your family leave to avoid losing benefits. FOR MORE INFORMATION ABOUT PFL, VISIT THE EDD WEB SITE AT OR CONTACT THE PAID FAMILY LEAVE CUSTOMER SERVICE CENTER AT: English Spanish Armenian Tagalog Cantonese Vietnamese Punjabi TTY (non voice) STATE GOVERNMENT EMPLOYEES SHOULD CALL NOTE: SOME EMPLOYEES MAY BE EXEMPT FROM COVERAGE BY THE ABOVE INSURANCE PROGRAMS. IT IS ILLEGAL TO MAKE A FALSE STATEMENT OR TO WITHHOLD FACTS TO CLAIM BENEFITS. FOR ADDITIONAL GENERAL INFORMATION, VISIT THE EDD WEB SITE AT DE 1857A Rev. 39 (11-08) (INTERNET) Page 1 of 1 GA 888/CU

62 DISABILITY INSURANCE PROVISIONS DE 2515 Rev. 57 (11-09) (INTERNET) Cover + 5 Pages CU/GA 892 B

63 Disability is any illness or injury, either physical or mental, that prevents you from doing your regular or customary work. Disability also includes elective surgery, pregnancy, childbirth, or related medical conditions. Disability Insurance (DI) is a component of the State Disability Insurance (SDI) Program and is designed to partially replace wages you lost because of a disability that was not caused by your work. (See Other Programs on reverse for job-related disabilities.) SDI taxes are paid by those California workers who are covered by the SDI program. Tax rates may vary from year to year. For current rates, contact the Employment Development Department (EDD) Disability Insurance Customer Service at or EDD Employment Tax Customer Service at DI Plans State Plan. DI s State Plan is covered in this brochure. Voluntary Plan. This is a private plan, approved by the Director of EDD, which may be substituted for the State Plan. Employers and employee groups may establish Voluntary Plans if the majority of employees and the employer agree to do so. If you are covered by a Voluntary Plan, the provisions of this brochure may not apply to you. Obtain information about your coverage and fi le a voluntary plan claim through your employer. Elective Coverage. Employers and self-employed persons, including general partners, may elect coverage. However, the method of computing benefits for elective coverage participants is not the same as for mandatory rate payers. The cost of participating, which is set annually, can be obtained from your local EDD Employment Tax Customer Service Offi ce. Elective Coverage claims are fi led in the same manner as State Plan claims; however, there are some differences in eligibility requirements from those listed in this pamphlet. For additional information or to apply for coverage, contact EDD Disability Insurance Customer Service at or EDD Employment Tax Customer Service at How to Claim State Plan Benefits 1. Request a claim form: By telephone at: By Internet at: By TTY (teletypewriter for deaf, hearing-impaired and speech-impaired persons only) at: for DI or for PFL. By writing EDD, Disability Insurance, P.O. Box 13140, Sacramento, CA In person by visiting any of the DI offi ces listed under DI Claim Management Offi ces. California State government employees covered by SDI should telephone Fill out and sign the Claim Statement of Employee. Print clearly, and be sure that your answers are complete and correct because errors may delay payments. 3. Have your doctor complete the Doctor s Certifi cate. Usually a claim cannot begin more than seven days before you were examined by or under the care of a certifying doctor. Certifi cation may be made by a licensed physician, surgeon, U.S. Government medical offi cer, osteopathic physician, chiropractor, podiatrist, optometrist, dentist, designated psychologist, or accredited religious practitioner. For normal pregnancy-related disabilities, certification may be made by a duly licensed nurse-midwife, nurse practitioner, or midwife. 4. Mail your claim form within 49 days from the fi rst day you were disabled. If your claim is late, you may lose benefits unless your explanation of the delay is accepted as reasonable. How Benefits Are Paid The SDI Program is designed to serve you by mail. You do not need to appear in person to apply for or receive benefi ts. When your claim is received, you may be contacted by mail or by telephone for additional information if needed. Most claims are processed within 14 days. The fi rst seven days of your disability claim are a non payable waiting period. DE 2515 Rev. 57 (11-09) (INTERNET) Page 1 of 5 CU/GA 892 B

64 Benefits are paid as quickly as possible after all information to determine eligibility is received. If you meet all eligibility requirements, benefi ts will be authorized. If you are eligible for further benefi ts, you will be sent additional benefi ts automatically or sent a continued claim certifi cation form for you to complete for the next benefi t period. Usually these benefit periods will be in two week intervals. However, the DI Program pays benefi ts based on daily eligibility within a seven-day calendar week. Partial weeks are paid at a daily rate. This rate is one-seventh of your weekly benefi t amount. Please allow ten days from the date you mail a certifi cation for receipt of your check. How Your Benefit Rate is Determined Your benefi t amounts are based on wages paid to you during a specifi c 12-month base period, which is determined by the date your claim begins. Therefore, you should carefully consider when to start your claim since this may affect your weekly benefi t rate, your maximum benefi t amount, and the period of your benefit eligibility. Only the wages in your base period that were subject to the disability insurance tax can be used in computing your benefits. To qualify, you must have earned at least $300 during your base period. The month in which your claim begins determines which four consecutive quarters must be used. If your claim begins in: January, February, or March, your base period is the 12 months ending last September 30. (Example: A claim beginning February 14, 2007, uses a base period of October 1, 2005, through September 30, 2006.) April, May, or June, your base period is the 12 months ending last December 31. (Example: A claim beginning June 20, 2007, uses a base period of January 1, 2006, through December 31, 2006.) July, August, or September, your base period is the 12 months ending last March 31. (Example: A claim beginning September 27, 2007, uses a base period of April 1, 2006, through March 31, 2007.) October, November, or December, your base period is the 12 months ending last June 30. (Example: A claim beginning November 2, 2007, uses a base period of July 1, 2006, through June 30, 2007.) Exceptions: If your claim is determined to be invalid, but you were unemployed and seeking work for 60 days or more in any quarter of your base period, you may be able to substitute wages paid in prior quarters. In addition, you may be entitled to substitute wages paid in prior quarters either to make your claim valid or to increase your benefi t amount, if during your base period you: were in the military service. received workers compensation benefi ts. did not work because of a labor dispute. If your situation fits any of the above, include a note with your claim form. Wage Continuation. If your employer continues to pay you wages while you are disabled, your DI benefi ts may be affected. DI benefi ts plus wages cannot exceed your regular weekly wage. Your DI benefi ts will not be affected by any vacation pay you may receive. Maximum Benefits. The maximum benefi t amount is 52 times the weekly rate, but not more than your total base period wages. Exception: For employers and self-employed individuals who elect SDI coverage, the maximum benefi t amount is 39 times the weekly rate. In addition, benefits are payable only for a limited period to a resident in a state-approved Alcoholic Recovery Home or Drug-Free Residential Facility. However, disabilities related to or caused by acute or chronic alcoholism or drug abuse, being medically treated, do not have this limitation. Pregnancy. As with any medical condition, your disability period begins the first day you are unable to do your regular or customary work. DI benefi ts are based on the period of time your doctor certifi es you are unable to do your regular or customary work. Do NOT send in your claim for pregnancy-related disability benefi ts until the date your doctor certifi es you are disabled. NOTE: For information on Paid Family Leave bonding benefi ts, see the Other Programs section of this brochure. DE 2515 Rev. 57 (11-09) (INTERNET) Page 2 of 5 CU/GA 892 B

65 You May Not be Eligible for Benefits If you are receiving Unemployment Insurance or Paid Family Leave benefi ts. If you are not working or looking for work at the time you become disabled. If you are in custody due to conviction of a crime. If your full wages are paid. If you are receiving workers compensation at a weekly rate equal to or greater than the DI rate. If workers compensation benefi ts are paid at a lower rate than your DI rate, you may be paid the difference. For the amount of time a claim is late (without good cause). If you make a false statement or fail to report a material fact. (A 30 percent penalty may be assessed if benefi ts are overpaid because you willfully withheld a material fact or made a false statement.) If you fail to attend an independent medical examination when requested. (Fees for such examinations are paid by EDD.) The California Unemployment Insurance Code provides for penalties consisting of fines, imprisonment, and loss of benefit rights for fraud against the Disability Insurance system. Your Rights. You are entitled to: Know the reason and basis for any decision that affects your benefi ts. Appeal any decision about your eligibility for benefi ts. (Appeals must be sent to the DI offi ce in writing.) A hearing of your appeal before an Administrative Law Judge (ALJ). You may further appeal the ALJ s decision to the California Unemployment Insurance Appeals Board and the courts. Privacy. Information about your claim will be kept confidential except for the purposes allowed by law. Your Obligations. You are responsible to: Complete your claim and other forms correctly, completely, and truthfully. Mail your claim and other forms in the time limits shown on the forms. If you are late and you believe you have a good reason for being late, you should include a written explanation of the reason(s) with the form. Contact DI if you do not understand a question or how to answer it. Include your name and Social Security number on all letters to DI. Contact DI By telephone at: (English) or (Spanish). By U.S. mail addressed to the office handling your claim and on the Internet at Contact_SDI.htm#bylocation. If you do not have a current claim, you may write to any DI Claim Management Offi ce. By TTY (teletypewriter for deaf, hearing-impaired, and speech-impaired persons only) at By at In person by visiting any of the DI Offices listed under DI Claim Management Offi ces. Other Programs IF YOU ARE INJURED ON THE JOB or become ill as a result of your occupation, notify your employer. IF YOU ARE ABLE AND AVAILABLE TO WORK but unemployed, contact the Unemployment Insurance Program of EDD at (TTY ). IF YOU NEED HELP IN FINDING WORK, JOB TRAINING, RETRAINING, or other services in order to return to work, visit your local one-stop career center listed in the white pages of your telephone directory and on the Internet at IF YOUR DISABILITY IS PERMANENT or is expected to continue for a year or more, contact the U.S. Social Security Administration at (TTY ) or on the Internet at DE 2515 Rev. 57 (11-09) (INTERNET) Page 3 of 5 CU/GA 892 B

66 IF A FAMILY MEMBER TAKES TIME OFF FROM WORK TO CARE FOR YOU, contact EDD s Paid Family Leave program at IF YOU TAKE TIME OFF FROM WORK TO BOND WITH A NEW CHILD, including newly adopted or newly placed foster children or those of your registered domestic partner, contact EDD s Paid Family Leave program at or TTY NOTE: A Paid Family Leave bonding claim form will be sent automatically with the fi nal benefi t check to new mothers receiving DI benefits. IF YOU ARE A VICTIM OF A CRIME, call the California Victims Compensation Program at TTY users may contact the Program via TTY at (English) or TTY at (Spanish). You may also contact your county Victim/Witness Assistance Center. QUESTIONS ABOUT SPOUSAL OR PARENTAL SUPPORT obligations should be directed to the District Attorney s Offi ce for the county that issued the court order. QUESTIONS ABOUT CHILD SUPPORT obligations should be directed to the Department of Child Support Services at DI Claim Management Offices Alameda Harbor Bay Parkway, Ste. 120 (write to: PO Box 1857, Oakland, CA ) Chico Salem Street (write to: PO Box 8190, Chico, CA ) Chino Hills Fairfi eld Ranch Road, Ste. 100 (write to: PO Box 60006, City of Industry, CA ) Fresno Mariposa Mall, Rm. 1080A (write to: PO Box 32, Fresno, CA ) Long Beach Long Beach Blvd., Ste. 600 (write to: PO Box 469, Long Beach, CA ) Los Angeles S. Figueroa Street, Ste. 200 (write to: PO Box , Los Angeles, CA N. Los Angeles Sherman Way, Rm. 500 (write to: PO Box 10402, Van Nuys, CA ) San Bernardino West 3rd Street (write to: PO Box 781, San Bernardino, CA ) San Diego Lightwave Avenue, Bldg. A, Ste. 300 (write to: PO Box , San Diego, CA ) San Francisco Franklin Street, Rm. 300 (write to: PO Box , San Francisco, CA ) San Jose West Hedding Street (write to: PO Box 637, San Jose, CA ) Santa Ana West Santa Ana Blvd., Bldg. 28, Rm. 735 (write to: PO Box 1466, Santa Ana, CA ) Santa Barbara East Ortega Street (write to: PO Box 1529, Santa Barbara, CA ) Santa Rosa Healdsburg Avenue (write to: PO Box 700, Santa Rosa, CA ) Stockton North Madison Street (write to: PO Box , Stockton, CA DE 2515 Rev. 57 (11-09) (INTERNET) Page 4 of 5 CU/GA 892 B

67 This pamphlet is for general information only, and does not have the force and effect of the law, rule or regulation. EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling DI at (voice), or TTY , or PFL at or TTY DE 2515 Rev. 57 (11-09) (INTERNET) Page 5 of 5 CU/GA 892 B

68 APPENDIX G

69 Don t forget! Be your own advocate. Talk with your employer before you return to work to see what support they can provide for you. Be patient. It takes practice to find out what works best for you and your baby. Ask for help if you need it. If you are offered a space at work but it doesn t suit your needs, talk to your employer about it. With little effort, you can be working and providing your baby with the best nutrition available: Mommy s breastmilk. Resources for help with breastfeeding Contra Costa Breastfeeding Advice Line Contra Costa WIC Peer Breastfeeding Counselors La Leche League toll free help line lalecheleague.org kellymom.org Working and Breastfeeding: You CAN do it! Funded by a Kaiser Community Benefit Grant.

70 Is it possible to work and breastfeed? The answer is YES! As of 2002, the law requires that employers offer lactation support to their employees. Lactating mothers should be provided with a private space that is not a restroom, and adequate break time for expressing milk. Returning to work after having a baby may seem overwhelming,, but asking for support from your employer will benefit you and your baby. Tips before returning to work 1. Take as much maternity leave as you can. These early weeks are important for bonding 2. Breastfeed often in the first weeks. This will help you establish a good milk supply. Supplementing with formula at this time may cause your body to make less milk 3. Ask your employer about a place to pump breast milk before you return to work. If they don t have one see if they can make an existing space private. You will only need to use it for about 20 to 40 minutes every 2 or 3 hours. Possible spaces could be someone s office, a storeroom, a women s lounge. You may need to have a locking door or a do not enter sign. A portable partition can be used, too. Think about where you will plug in your pump and wash your supplies. 4. Begin to store breast milk one or two weeks before you return to work. What should you expect? Managing breastfeeding and work takes practice. Try to give yourself time to figure out what works best for you. Here are some tips from other working moms! Breastfeed as much as you can when you re with your baby My workplace didn t have a lactation room so I asked my boss to help me find a place to pump privately. She put up blinds in her office and let me use it whenever I needed to I talked with my employer about giving me additional breaks to pump milk, before I returned to work