Form Wh-384385 - Employee Rights And Responsibilities Under The Family And Medical Leave Act Page 2

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ATTACHMENT A

H hone #

JEFFERSON COUNTY

REQUEST FOR FAMILY/MEDICAL LEAVE RIGHTS & RESPONSIBILITIES

Name

SS. #

Position

Dept.

Hire Date

Reason for requested leave:

a.  for the birth of my child, and to care for such child

b.  for the placement of a child with me for adoption or foster care

c.  to care for my spouse, child or parent with a serious health condition

d.  for my own serious health condition which has made me unable to perform my job

functions

e.  because of a qualifying exigency arising out of the fact that my spouse, son or

daughter, or parent is on covered active duty or call to covered active duty status with the Armed

Forces; or

f.  because I am the spouse, son or daughter, parent, next of kin of a covered servicemember

with a serious injury or illness.

Date on which you  wish to begin  began leave:

Date of anticipated return to work:

Are you requesting leave on an intermittent or reduced schedule?  Yes  No

If yes, please give schedule or when you anticipate you will be unavailable for work.

I understand that I must provide 30 days’ advance notice for requesting FMLA leave when the leave is foreseeable.

I also understand that a Certification of Health Care Provider Form (Attachment C)/Certification of Qualifying Exigency For

Military Family Leave Form (WH-384)/ Certification for Serious Injury or Illness of a Current Servicemember for Military

Family Leave Form (WH-385)/Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (WH-385-

V) must be completed by my health care professional and returned within 15 days after I notify you of this leave. I

understand that my leave may be delayed until I provide such certification from a physician. I understand that falsification

of any document or failure to produce required certifications relating to leave will result in discipline, up to and including

termination.

If my request for leave falls under 3e above, I understand a copy of the active duty orders or other documentation from the

military certifying the covered military member is on active duty (or has been notified of an impending call to active duty)

should be submitted within 15 days after I notify you of this leave by completing the Qualifying Exigency For Military Family

Leave Form (WH-384).

I hereby agree that while I am on leave I will continue to pay my portion of dependent health insurance premiums and

voluntary benefit premiums unless I elect to discontinue such coverage. I also agree that if I fail to return to work at the

end of the leave period, I will reimburse Jefferson County for the cost of health benefits provided by Jefferson County

during my leave, unless I fail to return to work because of the continuation, recurrence or onset of a serious health

condition or because of other circumstances beyond my control. If I am unable to return to work because of a serious

health condition, I will provide medical certification from the appropriate health care provider stating that I am unable to

perform the functions of my position on the date that my leave expired or that I was needed to care for a covered relation

because he/she has a serious health condition on the date that my leave expired. Employees seeking to return to work

after a leave because of their own serious illness (3.d) must furnish to the County a return-to-work release from the

attending physician before being allowed to resume work.

I understand I will be required to use all available paid leave in the following order; sick leave; compensatory time;

vacation; and personal leave, prior to being eligible for unpaid leave. All forms of paid leaves used run concurrently with

FMLA leave.

Signature

Date

Note: Nothing herein shall be construed as contradicting or superseding any portion of the FMLA or Jefferson County Policy. Any questions arising from use of this

form should be directed to the Human Resources Director.

Eff. 06/17

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