Family And Medical Leave Act (Fmla) Medical Certification Form

Your Rights

Under The

Family and Medical Leave Act of 1993

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-

discharge or discriminate against any person for opposing any practice

protected leave to “eligible” employees for certain family and medical reasons.

made unlawful by FMLA or for involvement in any proceeding under or

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relating to FMLA.

Reasons for Taking Leave:

Enforcement:

Unpaid leave must be granted for any of the following reasons:

The U.S. Department of Labor is authorized to investigate and resolve

complaints of violations.

to care for the employee’s child after birth, or placement for adoption or

foster care;

An eligible employee may bring a civil action against an employer for

violations.

to care for the employee’s spouse, son or daughter, or parent, who has a

serious health condition; or

FMLA does not affect any Federal or State law prohibiting discrimination, or

supersede any State or local law or collective bargaining agreement which

for a serious health condition that makes the employee unable to perform

provides greater family or medical leave rights.

the employee’s job

For Additional Information:

At the employee’s or the employer’s option, certain kinds of paid leave may be

substituted for unpaid leave.

Contact the nearest office of the Wage and Hour Division, listed

Advance Notice and Medical

in most telephone directories under U.S. Government,

Department of Labor.

Certification:

The employee may be required to provide advance leave notice and medical

certification. Taking of leave may be denied if requirements are not met.

The employee ordinarily must provide 30 days advance notice when the

leave is “foreseeable.”

An employer may require medical certification to support a request for

leave because of a serious health condition, and may require second or

third opinions (at the employer’s expense) and a fitness for duty report to

return to work.

Job Benefits and Protection:

For the duration of FMLA leave, the employer must maintain the

employee’s health coverage under any “group health plan.”

Employees are eligible if they have worked for a covered employer for at least

one year, and for 1,250 hours over the previous 12 months, and if there are at

least 50 employees within 75 miles.

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Upon return from FMLA leave, most employees must be restored to their

original or equivalent positions with equivalent pay, benefits, and other

employment terms.

The use of FMLA leave cannot result in the loss of any employment

benefits that accrued prior to the start of an employee’s leave.

Unlawful Acts by Employers:

FMLA makes it unlawful for any employer to:

interfere with, restrain, or deny the exercise of any right provided under

FMLA:

Please fax the completed forms to the correct processing center:

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Family And Medical Leave Act (Fmla) Medical Certification Form - Verizon West Page 8

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