Employee Application For Family Or Medical Leave Or Family Military Leave

ADDITIONAL INFORMATION REGARDING THE FMLA

Absences not covered by the FMLA: The following chart will be used for all employees in providing time off for absences not

covered by the FMLA.

Maximum Amount of Time Allowed in a Rolling 12-

Length of Employment

Month Period Counting Backwards

0 to 12 months

10 weeks

1 year, but less than 5 years

11 weeks

5 years, but less than 15 years

12 weeks

15 years, but less than 20 years

13 weeks

20 years, but less than 25 years

14 weeks

25 or more years

15 weeks

Pay during leave:

If your leave is because of your own serious health condition:

•

The first 32 hours will be paid using your PTO hours. If you don’t have PTO hours available, then your

banked sick hours will be used. If you don’t have banked sick hours available, then any time up to hour 33

will be unpaid.

•

If you are authorized to work 40 hours or more, then you are eligible to apply for short-term disability (STD).

STD provides 60% of your income from hour 33 until week 26 of your disability. The remaining 40% will be

paid using (in the following order) banked sick hours, PTO hours, or be unpaid if the employee elects.

If your leave is a Family Leave or Family Medical Leave, any time away from work will be paid using your

available PTO hours. If you don’t have PTO hours available, then time will be unpaid. After the first 32 hours

PTO hours will be used down to one week of authorized hours.

Your rights under the FMLA:

Deaconess provides family or medical leaves of absence and intermittent leaves of absence in accordance with the Family and

Medical Leave Act (FMLA) of 1993. All employees are eligible for up to 12 weeks of unpaid, job-protected leave if they have

been employed at least one year and have worked 1250 hours in the most recent twelve (12) month period counting backwards.

Reasons For Taking Leave

1. To care for employee's child after birth, or placement for adoption or foster care; or

2. To care for employee's spouse, son or daughter under the age of 18, or parent, who has a serious health condition; or

3. For a serious health condition that makes the employee unable to perform the employee's job for 3 consecutive calendar days.

Employees are required to utilize available paid benefit hours as provided in P&P 45-21. If the employee wishes and has time

available, remaining paid leave may be substituted for unpaid leave.

4. Family military leave to care for injured service member or for a qualifying exigency related to the covered military

member’s active duty or call to active duty status.

Advance Notice And Medical Certification

1. Employees must provide 30 days advance notice when the leave is "foreseeable".

2. A medical certification must be completed for leaves due to a serious health condition.

3. A second or third opinion, at Deaconess’ expense, may be requested.

4. A release to return to work from your healthcare provider will be required upon return to work.

Job Benefits And Protection

1. For the duration of FMLA, Deaconess will allow the employee to continue their health insurance at the current premium

Contribution amount.

2. Upon return from FMLA, employees will be returned to their original or equivalent position, pay, and shift.

3. FMLA will not result in the loss of any employment benefit that accrued prior to the start of an employee's leave.

Unlawful Acts By Employers: FMLA makes it unlawful for any employer to:

1. Interfere with, restrain, or deny the exercise of any right provided under FMLA;

2. Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any

Proceeding under or relating to FMLA.

Enforcement - The U.S. Department Of Labor is authorized to investigate and resolve complaints of violations. An eligible

employee may bring a civil action against an employer for violations.

For Additional Information - Contact the nearest office of the Wage and Hour Division, listed in most telephone directories

under U.S. Government, Department of Labor.

Employee Application For Family Or Medical Leave Or Family Military Leave - Deaconess Page 2

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