Family Medical Leave Act (Fmla) And Oregon Family Leave Act (Ofla) Forms Packet, Form Cd 1422 - Employee Medical Status Report


Oregon Department of Corrections
Family Medical Leave Act (FMLA) and
Oregon Family Leave Act (OFLA)
Forms Packet
Please read this statement before proceeding
This packet is a summary of Family and Medical Leave policy and procedures. In all cases applicable state
and federal laws, rules, policies and collective bargaining agreements govern the employee’s and the
agency’s rights and obligations; not this document.
FMLA and OFLA are not optional. The law requires the agency to provide these entitlements.
Federal and state law prohibit retaliation against an employee with respect to hiring or any other term or
condition of employment because the employee asked about, requested or used Family and Medical Leave.
Why am I receiving this packet?
It was requested by you, or
We were notified that you had an absence of more than three consecutive calendar days that may
qualify under FMLA and/or OFLA
What do I need to do next?
Have the medical provider complete the applicable form. There is an Employee Health Care Provider
Certification form and a Family Member Health Care Provider Certification form attached.
If you were incapacitated for more than seven days (for your own absence), have your medical provider
complete the attached Employee Medical Status Report (EMSR) form and return to your supervisor.
If you did not seek medical attention for your absence, please contact your FMLA/OFLA Analyst (listed
below) immediately.
Complete and submit a leave request within 3 days of your return to work.
Fax Completed Forms to (503) 362-2078
Margo Hammonds (503) 934-1013
Mon-Thurs 7:00-4:30p.m.; Fri 7:00-11:00a.m.
Christine Welter (503) 934-1036
CCCF, HS Admin, CDC, CTRS, Parole Board
Tues-Weds 7:00-4:00p.m.; Fri 7:00-11:00a.m.
Serena Thompson (503) 934-1083
MCCF, OSP, PRCF, Douglas, Linn
Mon, Tues, Thu 8:30-1:30p.m.; Fri 10:00-3:00p.m.
Angela Allen (503) 934-1057
Tues-Fri 7:00-5:30p.m.


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