Oregon Health & Science University Employee Request For Family Medical Leave (Fmla/ofla) Page 2
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2Family Medical Leave Policy
The rights and responsibilities of employees and OHSU under FMLA/OFLA are prescribed in OHSU Policy No. 03-25-015. Subjects include: eligibility,
reasons for leave, duration of leave, definitions, leave request and leave designation, reporting medical certification, continuation of benefits,
reinstatement, and failure to return to work after protected leave. Your rights and responsibilities for reinstatement to the same or an equivalent
position with the same pay, benefits and terms and conditions of employment on your return from FMLA and/or OFLA leave are listed in the policy.
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When leave qualifies under both OFLA and FMLA, the leave will be counted against the employee’s entitlement under both leave laws and the
employee’s entitlement will be reduced accordingly.
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You have a right under FMLA/OFLA for up to 12 weeks unpaid leave in a calendar year for qualifying reasons. Additional OFLA leave during
the calendar year may be taken for a condition related to pregnancy or childbirth that disables the employee or for “sick child care” as
prescribed in the policy.
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An employee who fails to return to work at the conclusion of an approved FMLA or OFLA leave may be deemed to have voluntarily terminated
his or her employment. Leave may be designated as FMLA/OFLA absence at the employer’s request.
Medical Certification
I understand a medical certification is required within 15 calendar days of my request to determine if my leave qualifies as a serious health condition
under the Federal Family and Medical Leave Act (FMLA) and/or the Oregon Family Leave Act (OFLA). A medical certification may also be requested by
policy, contract or if more than three days of leave are taken to care for a child with a health condition requiring home care.
Continuation of Benefits
Your health insurance benefits under FMLA must be maintained by OHSU up to 12 weeks during any period of leave under the same conditions as if you
continued to work. Your health insurance benefit will not be maintained during any unpaid OFLA leave but you will be offered continuation of coverage
under COBRA. If you do not return to work following the leave for a reasons other than: 1) the continuation, recurrence, or onset of a serious health
condition which would entitle you to leave; or 2) other circumstances beyond your control, you may be required to reimburse OHSU for any share of
health insurance paid on your behalf during the leave.
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You are required to use all accrued sick leave while on FMLA and OFLA.
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You may elect to continue insurance coverage under the other voluntary benefit plans (STD, LTD; supplemental life; spouse life; dependent
life.
I elect to
continue
decline my voluntary benefit plans.
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While on medical leave you are responsible for your portion of benefit premiums if any portion of your leave is unpaid from OHSU. Premiums
due will be deducted through payroll upon your return to work or you can pay them during your leave. Contact the Benefits Office for
information on the payment process.
While on Leave and Returning to Work
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While on leave, you may be required to furnish OHSU with periodic updates of your status and intent to return to work.
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If the circumstances of your leave changes and you are able to return to work earlier than the date indicated on the reverse side of this form,
you will be required to notify your manager at least two days prior to the day you intended to report to work and provide a written release
from your provider.
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You may be required to furnish re-certification relating to a serious health condition as prescribed in 825.308 of the FMLA regulations.
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If the leave is for your own serious health condition, you may be required to present a written release from your provider prior to being
restored to employment. If a written release is not received by your manager, your return to work may be delayed until a written release is
provided.
____________________________________________
_______________________________
Employee Signature
Date
FOR BENEFITS OFFICE USE
Proccess date__________________
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