Mta Family And Medical Leave Act Application Form printable pdf download

Family and Medical Leave Act Application Form

HR-BEN-028

Section 1 - Information and Instructions

The purpose of this form is to request a leave of absence under the Family and Medical Leave Act (“FMLA”).

Please mail or fax a signed copy of the completed form to your Agency Human Resources Department or FMLA Coordinator 30 days prior to the

start of your leave or as soon as possible. (MTAHQ and BSC Employees must forward completed forms to the BSC at fax#: 212-852-8700 or

)

If your request for FMLA is for you or a family member with a serious health condition, a medical certification is required. Therefore, please visit

the BSC Portal ( ) to download the applicable FMLA application and medical certification listed below:

a) HR-BEN-069 FMLA Certification of Health Care Provider Employee’s Serious Health Condition

b) HR-BEN-070 FMLA Certification of Health Care Provider Family Member’s Serious Health Condition

c) HR-BEN-071 FMLA Certification of Qualifying Exigency for Military Family Leave

d) HR-BEN-072 FMLA Certification for Serious Injury or Illness of Covered Service Member

Eligible employees requesting a leave under the FMLA may request a copy of the applicable policy, and the application and Certification of

Healthcare Provider form from their manager or the MTA Business Service Center by calling 646-376-0123. The policies and forms can be

downloaded from the BSC Portal ( ). An employee must request FMLA leave 30 days prior to the start of the leave, unless

such notice is not practicable, in which case, the employee must provide notice as soon as possible.

The FMLA provides eligible employees with up to 12 weeks of unpaid leave for the following reasons: (1) incapacity due to pregnancy, prenatal

medical care or childbirth; (2) to care for a child after birth, or placement for adoption or foster care; (3) to care for a spouse, child, or parent who

has a serious health condition; (4) for the employee's own serious health condition that makes them unable to perform their job; and (5) to

address certain qualifying exigencies if a spouse, child or parent is on active duty or called to active duty in a foreign country. The FMLA also

provides up to 26 weeks of leave to care for a covered service member who has a serious illness or injury under certain circumstances.

If you have any questions about FMLA leave, please contact the MTA Business Service Center at (646) 376-0123 or .

Section 2 - Employee Information

BSC ID

Print Name

Agency ID

Last

First

M.I.

Suffix

Department

BSC

B&T

Police

Agency/De

NYCT

Job Title

(check

SIR

LIRR

MNR

MTA Bus

one)

MaBSTOA

Reg Work Sched

Street Address

City

State

Zip Code

Phone (H)

Phone (W)

Section 3 – Reason For Leave

Please Check only one:

My own serious health condition or pregnancy renders me unable to perform the functions of my position.

The birth and/or care of a child within 12 months of date of birth. (Provide verification of Date of Birth)

The placement with me of a child for adoption or foster care, or to care for a child

To care for my

spouse,

child, or

parent with a serious health condition.

(Child’s DOB:

Qualified exigency leave for my

spouse,

child, or

parent on active duty or called to active duty in a foreign county

To care for my

spouse,

child,

parent, or

next of kin who is a covered service member with a serious injury or illness,

□

for my pregnant spouse.

Business Service Center

Last Revised: 12/06/2016

Creation Date: 04/01/2012

Mta Family And Medical Leave Act Application Form

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