Form Wh-384385 - Employee Rights And Responsibilities Under The Family And Medical Leave Act Page 3
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16ATTACHMENT B
JEFFERSON COUNTY
EMPLOYER NOTICE OF ELIGIBILITY/RIGHTS & RESPONSIBILITIES/DESIGNATION OF
FAMILY/MEDICAL LEAVE
Date:
To:
SS#
(Employee’s Name)
Subject:
Designation of Family/Medical Leave
On ___________________, you notified us/we became aware of your need to take family/medical leave due to:
(date)
a.
the birth of a child, or the placement of a child for adoption or foster care; or
b.
a serious health condition that you need to care for; or
c.
spouse,
child,
parent for which
a serious health condition affecting your
you are needed to provide care; or
d.
because of a qualifying exigency arising out of the fact that your spouse, son or daughter,
or parent is on covered active duty or call to covered active duty status with the Armed
Forces; or
e.
because you are the spouse, son or daughter, parent, next of kin of a covered
servicemember with a serious injury or illness.
This leave will begin began on or about _________________ and you expect the leave to continue until
on or about _______________.
(date)
(date)
You have a right under the FMLA for up to 12 workweeks of unpaid leave in a rolling 12-month period (unless
you have paid leave available to you) for the reasons listed above (under a, b, c, and d).
For a serious injury or illness of a covered servicemember (military caregiver leave) you have a right under the
FMLA for up to 26 workweeks of unpaid leave in a 12-month period (unless you have paid leave available to
you) for the reason listed above under e. For an eligible employee with a spouse, son, daughter, or parent on
covered active duty as an active duty servicemember or call to covered active duty status Armed Forces you
may use the 12 workweek leave entitlement to address certain qualifying exigencies.
Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if
you continued to work, and you must be reinstated to the same or an equivalent job with the same pay, benefits,
and terms and conditions of employment on your return from leave. If you do not return to work following FMLA
leave for a reason other than: (1) the continuation, recurrence, or onset of a serious health condition which
would entitle you to FMLA leave; or (2) other circumstances beyond your control, you may be required to
reimburse us for our share of health insurance premiums paid on your behalf during your FMLA leave.
This is to inform you that (check appropriate boxes; explain where indicated):
1. You are eligible not eligible for leave under the FMLA.
2. The requested leave will will not be counted against your annual FMLA leave entitlement.
Eff. 06/17
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