Employee Application For Family Or Medical Leave Or Family Military Leave

EMPLOYEE APPLICATION FOR FAMILY OR MEDICAL LEAVE OR FAMILY MILITARY LEAVE

DEACONESS

Name_______________________________ ID No.:_______________ Department:

Date of Hire: ______________Authorized Hours per pay period :

Name of Supervisor

Supervisor’s Ext.:

Instructions:

•

Complete and return this form within 2 calendar days of the beginning of your leave. Complete all areas. Keep a copy for

your records.

•

The Certification of Health Care Provider OR Attending Physician Statement form must be completed and submitted to

Human Resources within 15 days of notification from Human Resources. The person with the serious medical illness

must be seen in person by the healthcare provider within 7 calendar days from the first day of incapacity.

•

Refer to the reverse side of this form and Policy and Procedure 45-21, “Family and Medical Leave and Other Absences”, for

more information.

Short-Term Disability (STD): If you are going to be off more than 32 hours for your own medical illness and

your authorized hours are 40+ per pay period, you need to apply for STD. Forms are available in Human

Resources and we can use the Medical Certificate from UNUM for both STD and FMLA. While receiving

STD pay if you do not want Deaconess to supplement the 40% not paid by UNUM using your PTO accrual

please notify Human Resources.

Beginning Date of Absence:

Return to Work Date:

Why are you applying for family or medical leave?

I am applying for Employee Medical Leave (employee’s serious health condition, worker’s compensation, or

Maternity).

I am applying for short-term disability

I am applying for Family Medical Leave to care for a spouse, child or parent.

I am applying for Family Leave (extension of maternity leave to care for newborn child or to care for adopted

or foster child).

I am applying for family military leave

I am not applying for a leave (will count as an occurrence of absence).

I am applying for Intermittent Medical Leave due to a chronic condition. State the medical reason for

Intermittent Medical Leave:

Are you a salaried supervisor?

Yes

Authorization and Signature: I understand that a health care provider, a human resources professional, or a

leave administrator representing Deaconess may contact my physician for clarification and authentication of

the medical certification. I understand the terms and conditions of a leave as stated in this document and

hospital P&P 45-21, “Family and Medical Leave and Family Military Leave.”

Employee’s Signature:

Date:

Please see the reverse side of this form for additional information regarding the FMLA.

FOR HUMAN RESOURCES USE ONLY:

Hours worked: ___________ As of PPE: ______________ NonFMLA Weeks: ________

Approved:

Yes

No Date: __________ Intermittent Date: _________ Requests:

Chronic :

Long-term:

Time used in Past 12 Months: FMLA: _____ Weeks _____ Hours /

NonFMLA: ______Weeks ____Hours PPE:________

F-0401 (5-09)

Employee Application For Family Or Medical Leave Or Family Military Leave - Deaconess

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