Report Under P.G. 205-21 POLICE DEPARTMENT CITY OF NEW ...

1 1 Report Under 205-21 POLICE DEPARTMENT CITY OF NEW YORK From: Commanding Officer, Military and Extended Leave Desk To: Uniformed Members of the Service Subject: INSTRUCTIONS AND FORMAT TO FOLLOW WHEN REQUESTING A LEAVE OF ABSENCE WITHOUT PAY, Under THE FAMILY AND MEDICAL LEAVE ACT. 1. Prepare a Report using the attached sample and format as a guide. This Report will be addressed to your Commanding Officer and forwarded to this command after the endorses the request (after conferral with the Borough Commander).

2 All doctor s notes submitted in connection with this leave request, must be original and written on official letterhead. 2. You must surrender all DEPARTMENT property, as listed on the Discontinuance of Service Form before starting this leave to your Commanding Officer. Restricted/HQ Annex Parking Permit must be returned to the Integrity Control Officer at your command. All DEPARTMENT property will be recorded on the Property Receipt-Discontinuance of Service Form, the original will be forwarded, along with the green copy of the Property Clerk s Voucher, to the Commanding Officer, Military and Extended Leave Desk.

3 If applicable, all members must return their personal portable radio with all accessories to Communications Division, Electronics Section 50-16 59th Place, Woodside, NY 11377. If applicable, all members, must return their personally assigned cellular telephones and all accessories to Communications Division, Telecommunications Unit, One POLICE Plaza, Room 910B. Metro Card must be delivered to Employee Management Division located in 1 POLICE Plaza, Room 1014 (this will be noted on Property Receipt-Discontinuance of Service Form or on a separate receipt).

4 All members of the service MUST forward their Shield and Identification Card to the Shield and ID Unit, 1 POLICE Plaza, Room 502. Attach a copy of all property receipts to leave request package. 3. All accrued vacation and other accrued leave MUST be exhausted prior to start of leave. As a uniformed member, vacation is granted January 1st for that year. You DO NOT accrue vacation while on an UNPAID leave, thus vacation may not be taken before a leave which includes vacation time which would have accrued during the months you are on a leave of absence.

5 If vacation time was already taken, it will be deducted from your vacation allowance for the following year when you return to active 2employment with the NYCPD. You must reimburse the NYCPD for vacation days which you were paid, but were not earned. 4. While on this leave of absence without pay, you may be entitled to twelve (12) weeks of health insurance Under the Family and Medical Leave Act ( fmla ). If you have any questions concerning your health insurance coverage, please contact the Health Insurance Section at (646) 610-5122. 5. After the leave of absence is approved, you will be transferred to the Military and Extended Leave Desk (MELD), located at 1 POLICE Plaza, New York, NY.

6 , Room 1008. If you plan to terminate your leave prior to its scheduled expiration date, contact MELD for an appointment. You must notify the Commanding Officer, Military and Extended Leave Desk, in writing of any change of address or telephone number while on leave including any temporary change of address or telephone number. If you are permanently changing your address or telephone number, you will need to officially inform the DEPARTMENT by preparing form PD451-021 (Change of Name, Residence or Social Condition). 6. You must not accept outside employment while on this leave without the DEPARTMENT s prior approval, obtained through the Commanding Officer, Military and Extended Leave Desk, by submitting an Off-Duty Employment Application (PD407-164), as per Patrol Guide Procedure 205-40.

7 7. While on leave, you will respond to and make all court appearances for any DEPARTMENT hearings or trials that are pending in which you are a witness, arresting officer, or respondent. In addition, all Members of the DEPARTMENT must Report all POLICE Incidents/Off-Duty Incidents as per Patrol Guide Procedure 212-32, and any Family Offenses and Domestic Violence, involving Members of the DEPARTMENT , as per Patrol Guide Procedure 208-37. 8. If you have any further questions, please call the Military and Extended Leave Desk at (646) 610-5513. Rebecca Mayo Sergeant , Military and Extended Leave Desk Rev.

8 05/11 3 SAMPLE FORMAT SAMPLE FORMAT POLICE DEPARTMENT CITY OF NEW YORK Date _____ From: Janice Jones; Shield# 9999; Tax# 999999; SS# 9999 To: Commanding Officer, 099 Precinct Subject: REQUEST FOR A LEAVE OF ABSENCE WITHOUT PAY, Under THE FAMILY AND MEDICAL LEAVE ACT ( fmla ) 1. It is requested that I be granted a twelve (12) week leave of absence without pay, Under the provisions of the Family and Medical Leave Act, from 0001 hours, _____ to 2400 hours, _____.

9 This leave is being requested so that I may care for _____ (sick parent, child or spouse). I am enclosing medical documentation to substantiate this request. 2. In this paragraph, state in detail why you are requesting this leave and submit any documentation you may have, letter from an attending physician giving a diagnosis and prognosis of the person to be cared for, (certification of physician or other health care provider). The medical documentation must state that you, the employee, will be the full time care giver. 3. As a uniform member appointed on _____, I understand that I am not entitled to use any annual vacation which would have accrued while on this unpaid leave and I must use all other accrued time which I have earned prior to commencing this leave.

10 I further understand that if I have already taken any vacation which would have accrued while on this leave, such leave will be deducted from the next year s allowance. If for any reason, I do not return to active employment with the New York City POLICE DEPARTMENT , I must reimburse the New York City POLICE DEPARTMENT for vacation days I was paid, but did not earn. 4. I have worked for the New York City POLICE DEPARTMENT for at least one year, and for 1250 hours over the previous 12 months. I understand that while on this leave of absence, my health insurance will be paid for by the City of New York for up to 12 weeks.