Family Medical Leave Act (FMLA)

This form is for the certification of health care provider for employee's serious health condition under the Family and Medical Leave Act.

This form is for the certification of health care provider for family member's serious health condition under the Family and Medical Leave Act.

This form is for the certification for military family leave for qualifying exigency under the Family and Medical Leave Act. 

Eligible employees may request Family Medical Leave for:

• Serious health condition of the employee
• Serious health condition of a qualified immediate family member
• The birth, adoption, or placement for foster care of a child with the employee
• Qualifying exigencies that arise while a covered service member (who is the employee's spouse, child, or parent) is on covered active duty, called to covered active duty or has been notified of an impending call or order to covered active duty in the Armed Forces or
• To care for a covered service member with a serious injury or illness. 

For purposes of the FMLA, immediate family is defined as the employee's spouse, child under the age of 18 (or older if certified as incapable of self-care because of a mental or physical disability), and the employee's parents (but not parents-in-law). Refer to the College's FMLA Policy for further details on these immediate family definitions.

The FMLA requires only that unpaid leave be granted in qualifying circumstances. However, an employee must use available sick leave for their own serious health condition and may use sick and annual leave in other situations as set forth in the College's FMLA Policy. The use of annual or sick leave must meet the requirements set forth in College Policies and State Regulations.

Except for certain limited situations specified in the FMLA, employees returning from approved Family Medical Leave are entitled to be restored to the position held immediately prior to the leave, or to an equivalent position with equivalent employment benefits, pay and other terms and conditions of employment.

Eligible employees make take intermittent leave when medically necessary based on the serious health condition of the employee, a covered family member, or the serious injury or illness of a covered service member or for a qualifying exigency. Family Medical Leave may not be taken intermittently for the birth or placement of a child unless the employee's immediate supervisor and the Office of Human Resources agree otherwise.

If you are taking unpaid Family Medical Leave, you must continue your normal premium payments during the period of leave to keep your insurance benefits active. The College will continue to pay its portion of your premiums while you are in covered FMLA status.

If you are out on unpaid leave longer than the authorized FMLA leave entitlement period, you will be responsible for paying both the College's portion and your own premiums if you wish to keep your insurance active. 

If you do not elect to keep your insurance in force during the period of unpaid leave, you may re-enroll upon returning from Family Medical Leave. You will not be required to meet any qualification requirements under the plan, such as a new pre-existing condition waiting period or a medical examination for reinstatement of coverage. 

If you fail to return to work based on certain circumstances within your control following the expiration of Family Medical Leave, you may be required to repay the College's portion to the insurance premiums paid for any period of unpaid leave. 

You must provide a physician's release upon your return to work following absences related to your own serious health condition.

Requests for Family Medical Leave should be made by contacting the College's Office of Human Resources. You will be provided with the appropriate certification form, which you must have completed and returned to the Office of Human Resources within 15 days of receipt.

If the Family Medical Leave is for the adoption or placement of a child in foster care, you may be required to present satisfactory proof such as a copy of the adoption papers or letter from the attorney or official handling the adoption or foster care agreement. In the case of either qualifying exigency or military caregiver leave, you may be required to provide documentation or statement of family relationship, certain military documentation and a proper certification related to the need for leave. 

When requesting Family Medical Leave you must, when foreseeable, give 30 days advance notice to the College of the need to take Family Medical Leave. When 30 days is not possible, you must provide notice as soon as practicable and comply with the College's normal call-in procedures.

The College's Office of Human Resources has the responsibility to declare leave as FMLA qualified based on the information provided by the employee and the certification information.