Grcc Family And Medical Leave (Fmla) Request Form - Grand Rapids Community College

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MEMORANDUM 
 
TO:  GRCC Employee 
FROM:  Human Resources 
SUBJECT:  Family Medical Leave Act Information  
 
Attached is information on the Family and Medical Leave Act of 1993. Employees are eligible if they 
have worked for Grand Rapids Community College at least 12 months, and have worked at least 1,250 
hours over the past 12 months. Various medical conditions are appropriate for Family and Medical 
Leave, such as continuing treatment for chronic or long‐term medical conditions.  
 
If FMLA leave is appropriate for you, please complete the Family and Medical Leave Request form 
before you begin your leave. This form needs to be complete with your signature and the signature of 
your supervisor. Return to your Human Resource Generalist upon completion.  
 
 Also, complete the top portion of the front page of the Certification of Health Care Provider form. 
Include the employee’s name and department, or if applicable, the patient’s name and relationship to 
the employee. The attending physician must complete the remainder of the form.  Once this form is 
completed by your physician, please return to your Human Resource Generalist. Your physician may fax 
the form to Human Resources.  
 
Attached you will find the GRCC policy on Family and Medical Leave, Information on FMLA,  the Family 
and Medical Leave Request form, and the Certification of Health Care Provider form.  
 
If you should have any questions, please call (616) 234‐3972.  
 
 
Human Resources 
Phone: (616) 234‐9372 
Fax: (616)234‐3907 
hr@grcc.edu 
 
 
 
 

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