Family Medical Leave Employer Instructions and Forms

1 Professional Employer Organization (PEO) Services are sold and provided by Paychex Business Solutions, LLC and its affiliates. Paychex, Inc. 2018 9/18 Family Medical Leave Employer Instructions and Forms When you become aware of an employee s need for Family or Medical Leave * complete the following: Provide the employee with a request for Family / Medical Leave under the fmla form. Have the employee complete the form and return it to their supervisor or other designated company representative for approval or denial of Leave . After the completed request for Family / Medical Leave under the fmla form has been received and reviewed, complete the Notice of Eligibility and Rights & Responsibilities ( Family and Medical Leave Act) WH-381 form and the Designation Notice ( Family and Medical Leave Act) WH-382 form, and give to the employee via hand delivery or certified mail.

2 If Leave is due to the employee s own serious health condition, or to care for a covered Family member with a serious health condition, to care for a covered servicemember or veteran with a serious injury or illness or for a qualifying exigency arising out of the fact that covered Family member is on active duty, also provide the employee with the appropriate certification form (refer to WH-380E, WH-380F, WH 384, WH 385, and WH 385V). Inform employees that Medical certification must be returned within 15 days of request for Leave , or as soon as practicable. Employers may wish to consult with their legal counsel for advice on whether the US Department of Labor s Certification of Health Care Provider for Employee s Serious Health Condition (WH 380E), Certification of Health Care Provider for Family Member s Serious Health Condition (WH 380F), Certification of Qualifying Exigency for Military Family Leave (WH 384), Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (WH 385), and Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (WH 385V)

3 , developed by the DOL (available at ) comply with the Genetic Information Nondiscrimination Act (GINA) regulations or whether they should attach to the DOL fmla form(s) a separate page containing the safe-harbor language. A sample of such a form can be found at the end of this packet. If Leave is granted, complete the Employee Change/Termination Form (PEO083) and submit it to the PBS Payroll Department. Note: This form must also be completed when the employee returns from Leave . If you have a consistently enforced policy which requires employees to periodically check in while on Leave and have indicated this policy on the Notice of Eligibility and Rights & Responsibilities ( Family and Medical Leave Act) WH-381 form, you may wish to use the Schedule of Employee Periodic Reports During Leave form for tracking purposes.

4 If the employee is taking Leave due to their own serious health condition, and you have a consistently enforced policy which requires employees to provide a fitness for duty certificate prior to their return to work from Leave and have indicated this policy on the Designation Notice ( Family and Medical Leave Act) WH-382 form, provide the employee with a Return to Work Medical Certification form to be completed by the employee and the employee s health care provider prior to returning to work. * Family / Medical Leave may run concurrently with workers compensation Leave , disability Leave ,and/or other state or company provided leaves.

5 For assistance in determining whether an employee s need for Leave is covered under federal and/or state Leave laws, refer to your employee handbook and/or contact your Paychex HR Solutions PEO HR Generalist. request for Family / Medical Leave under the fmla In order to be eligible for up to 12 weeks (or 26 weeks for Military Caregiver Leave ) of unpaid Leave (in a 12-month period) under the Federal Family and Medical Leave Act ( fmla )*, the following criteria must be met: You have worked for the Company for at least 12 months (need not be consecutive months, butemployment periods prior to break in service of seven years or more need not be counted).

6 You have worked at least 1,250 hours in the 12 months preceding this request for Leave . At the time Leave is requested, you either a) work at a worksite with 50 or more employees, or b) work at aworksite where 50 or more employees are employed by the covered Employer within 75 miles of thatworksite.*State law may provide greater Leave rights. Refer to your employee handbook for state and federal leavepolicies, if applicable. Employee to Complete You are expected to comply with the Company s usual and customary notice and procedural requirements for requesting Leave , absent any unusual circumstances. If your need for Family / Medical Leave is foreseeable, you must give at least 30 days advance written notice.

7 If this is not practicable, you must give notice as soon as practicable under the facts and circumstances of your particular situation (generally within one or two business days of learning of your need for Leave ). Employee Name Address Department _____ Position Manager Status (select one) Full-time Part-time Date of Hire / / I hereby request a Leave of absence effective on / / (date you are requesting Leave to commence). My estimated return to work date is on / / . Reason for Requested Leave Birth of a child of the employee and to care for such child. Placement of a child with employee for adoption or foster care.

8 To care for a spouse, child, or parent with a serious health condition. Family Member Name Relationship If Family member is a child, is the child under 18 years of age? Yes No Employee s own serious health condition. To handle certain qualifying exigencies arising out of the fact that the employee s spouse, son, daughter, or parent is on duty under a call or order to active duty in the Uniformed Services. See your company s policy for more details regarding Military-Related fmla Leave . Family Member Name Relationship To care for a member of the Armed Forces or a veteran with a serious injury or illness related to certain types of military service.

9 Such service member must be the employee s spouse, son, daughter, parent, or next of kin. See your company s policy for more details regarding Military-Related fmla Leave . Family Member Name Relationship Are you requesting Leave on an intermittent or reduced-schedule Leave ? Yes No If "Yes," please describe your proposed schedule. _____ _____ _____ _____ / / Employee SignatureDateEMPLOYEE RIGHTSUNDER THE Family AND Medical Leave ACTE ligible employees who work for a covered Employer can take up to 12 weeks of unpaid, job-protected Leave in a 12-month period for the following reasons: The birth of a child or placement of a child for adoption or foster care; To bond with a child ( Leave must be taken within 1 year of the child s birth or placement); To care for the employee s spouse, child, or parent who has a qualifying serious health condition.

10 For the employee s own qualifying serious health condition that makes the employee unable to perform the employee s job; For qualifying exigencies related to the foreign deployment of a military member who is the employee s spouse, child, or eligible employee who is a covered servicemember s spouse, child, parent, or next of kin may also take up to 26 weeks of fmla Leave in a single 12-month period to care for the servicemember with a serious injury or illness. An employee does not need to use Leave in one block. When it is medically necessary or otherwise permitted, employees may take Leave intermittently or on a reduced schedule.