Form Wh-384385 - Employee Rights And Responsibilities Under The Family And Medical Leave Act Page 4
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16Attachment B – Continued
3. You are required to furnish medical certification of a serious health condition and you must furnish this
certification within 15 days after you are notified of this requirement or we may delay the commencement of
your leave until the certification is submitted. If sufficient information is not provided in a timely manner, your
leave may be denied.
4. In accordance with County policy, any useable accrued paid leave must be used first, in the following order
during the 12 workweek or 26 workweek leave period to care for an injured or ill servicemember: 1) sick
leave, 2) compensatory time, 3) vacation or 4) personal leave, where applicable. An employee who is
taking leave for the adoption or foster care of a child or military FMLA leave for a qualifying exigency
must use all paid compensatory time, vacation and personal leave prior to being eligible for unpaid
leave. Once any paid leave is used up, the remainder of the 12 workweeks will be unpaid.
5. If you normally pay a portion of the premiums for your dependent’s health/dental insurance, and/or other
optional benefits, these payments must continue during the period of FMLA leave. Your premium payments
are due on regularly scheduled County paydays.
6. You will be required to present a fitness-for-duty certificate prior to being restored to employment. If such
certification is not received, your return to work may be delayed until such certification is provided.
7. You are required to furnish us with periodic reports of your status and intent to return to work every 30 days
while on FMLA leave.
8. You are required to furnish recertification every six (6) months in relation to a serious health condition.
9. Failure to comply with any of the above conditions may result in disciplinary action.
The above information has been reviewed with me and I agree to comply with the provisions herein.
Leave approved by:
Date
(Department Head’s Signature)
Employee’s Signature
Eff. 06/17
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