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TRAIN AND ENGINE

FAMILY MEDICAL LEAVE / FAMILY MILITARY LEAVE (FML)

Dear Employee,

Please read this letter carefully. It is your responsibility to follow the outlined steps to initiate

family medical leave / family military leave. If you do not complete the application for leave and

submit the complete provider certification (if leave is due to a serious health condition), we will be

unable to process your request. For a planned leave, notify both APS (toll free) at

888-257-3407

and your supervisor of your actual last day of work and first day of leave 30 days prior to taking

leave. In the event of an unplanned leave, please contact your supervisor and APS Healthcare as

soon as possible.

At this time, the time off of work you have requested will be counted as family medical leave / family

military leave. If it is later determined that you are not eligible for family medical leave / family military

leave or this absence does not meet the requirements under family medical leave, your time off may not

be counted as family medical leave / family military leave and the absence will be treated as unexcused.

Norfolk Southern has contracted with APS Healthcare to administer and manage family medical leave /

family military leave for certain Norfolk Southern employees such as yourself. You must complete the

enclosed application and return it to APS Healthcare as soon as possible. Also, if your leave is due to a

serious health condition either for you or your family member, you must take the provider certification form

to the treating healthcare provider for completion. The completed forms must be submitted to APS by

mail or fax within 15 days of your request

APS Healthcare

Disability Department

300 North Executive Drive

Suite 300

Brookfield, WI 53005

FAX: 262-787-2507

APS will provide on-going assistance to you while you are on leave and may contact you and/or your

physician concerning your request for family medical leave.

Finally, if you are absent due to your own serious health condition, please utilize the attached fitness for

duty form when a return to work date is identified.

If you have any questions or concerns, you may contact APS at 1-888-257-3407 or Paul Strickland in the

Norfolk Southern HR Department at 1-757-629-2441.

Enclosures:

(1) Notice of Rights and Obligations under the Family and Medical Leave Policy

(2) Request form

(3) Certification of Healthcare Provider form or Military Leave Certification

(4) Fitness For Duty [if applicable]

Updated 04/14/2011

Family Medical Leave / Family Military Leave (Fml) Request Form - Aps Healthcare Disability Department