ࡱ> y Ιbjbj 7{{. bbbvvvvv@ vw D $;>>>>>>$A{D>b " >K?!!! F8b;! ;!!z6J8.к$%!:27:?0@J78QE_!QE08QEb8l! >>u! @ QE : State of MichiganLeave of Absence Application For FMLA, Medical (Including Extended Use of Leave Credits), and Parental Leaves Only Contact your HR Office for the appropriate form for other leaves of absence Employee completes Section I (Page 1) ONLY: Sections II and III are completed by the HR or Disability Management OfficeSection I Request for Leave of Absence Completed by EMPLOYEE An employee may complete and submit Section I of this form to the CSC Disability Management Unit, 400 S. Pine St., P.O. Box 30002, Lansing, MI 48909 or if directed, to your HR Office. Until your leave is approved, you must follow your departments normal call-in procedures. It is your responsibility to notify your supervisor of your leave request, and how to enter your time on your timesheets.1. Employees Name  FORMTEXT      2. Employee s ID Number  FORMTEXT      3. Department Name  FORMTEXT      4. Home Address  FORMTEXT      5. Home E-Mail (optional)6. Telephone Numbers Work (  FORMTEXT     )  FORMTEXT     -  FORMTEXT      Home (  FORMTEXT     )  FORMTEXT     -  FORMTEXT      Cell (  FORMTEXT     )  FORMTEXT     -  FORMTEXT     7. Supervisor Name  FORMTEXT      8. Supervisor Phone (  FORMTEXT     )  FORMTEXT     -  FORMTEXT     9. Dates of Leave Requested From:  FORMTEXT       To:  FORMTEXT        FORMCHECKBOX  Check if Intermittent Leave or Reduced Work Schedule10. Reason Leave Requested:  FORMCHECKBOX  A serious health condition that makes you unable to perform the essential functions of your job.  FORMCHECKBOX  A serious health condition affecting your  FORMCHECKBOX spouse,  FORMCHECKBOX child,  FORMCHECKBOX parent, for which you are needed to provide care.  FORMCHECKBOX  The birth of a child, or the placement of a child with you for adoption or foster care on  FORMTEXT       (date). If parental leave will follow release from medical leave, indicate the parental leave effective date:  FORMTEXT       .  FORMCHECKBOX  A qualifying exigency arising from the employee s  FORMCHECKBOX spouse,  FORMCHECKBOX child, or  FORMCHECKBOX parent being on covered active duty or having been notified of an impending call or order to covered active duty in the Armed Forces.  FORMCHECKBOX  To care for a covered servicemember for whom the employee is  FORMCHECKBOX spouse,  FORMCHECKBOX child,  FORMCHECKBOX parent, or  FORMCHECKBOX next of kin.11. Leave Credits to be Used, if eligible* Sick Leave must be exhausted prior to an unpaid Medical Leave of Absence for personal illness, except as noted below. *Refer to your Collective Bargaining Agreement (CBA), department policy or Civil Service (CS) regulations for more information as employees may use other leave credits to remain in pay status or freeze them in accordance with these procedures. If your sick leave will exhaust before you return to work, please specify your preferred use of other leave credits. If no preference is stated, all other leave credits will be frozen. Annual Leave: Use all  FORMCHECKBOX  or # of hours to freeze:  FORMTEXT     Banked Leave: Use all  FORMCHECKBOX  or # of hours to freeze:  FORMTEXT     Comp Time: Use all  FORMCHECKBOX  or # of hours to freeze:  FORMTEXT     DeferredHours: Use all  FORMCHECKBOX  or # of hours to freeze:  FORMTEXT     Sick Leave (Family Care, Military Caregiver Leave, or MSP Employees Only): Use all  FORMCHECKBOX  or # of hours to freeze:  FORMTEXT     Note: To ensure you are paid correctly, you must let your supervisor or timekeeper know you are freezing leave credits.ACKNOWLEDGEMENTI understand this leave, if approved, may count towards my leave entitlements under the federal Family and Medical Leave Act, Civil Service rules, department policy and collective bargaining agreements, if I am eligible and the absence qualifies. I certify that my leave credits should be used as stated above, where authorized and I understand that my selections are binding.Employee Signature Date Section II Family Medical leave Act (FMLA) Notice of Eligibility, Rights, and Designation/Eligibility Determination and Required Certifications Completed by Disability Management Office or Human Resources1. Employees Name 2. Employees ID Number 3. Eligibility Determination. On ________________ (date) you informed us that you needed FMLA leave.  FORMCHECKBOX  You are eligible for leave under the FMLA. You appear to be eligible for _______________ (remaining time) for the rest of your 12-month FMLA entitlement period ending _____________ (date) for  FORMCHECKBOX  servicemember family leave  FORMCHECKBOX  other FMLA leave. (Complete rest of Section II before signing and providing form to employee.)  FORMCHECKBOX  You are not eligible for leave under the FMLA. (Explain why, sign form, and provide to the employee.)  FORMTEXT       If eligible, you have a right under the FMLA for up to 12 weeks of leave in a 12-month period for the first four qualifying reasons listed in Section I, #10. You also may be eligible for up to 26 weeks of leave in a 12-month period for qualifying care for a covered servicemember, although any other FMLA leave taken during that period will count toward your 26-week entitlement. Your health benefits can be maintained during any period of unpaid FMLA leave as if you continued to work. You must be reinstated to the same or an equivalent job with the same pay, benefits, and conditions of employment on your timely return from leave. You may have other leave options under civil service rules or a collective bargaining agreement. If circumstances change and you can return early, you must notify us at least two work days before you intend to report to work. Clarification and notice of your rights and responsibilities under the FMLA follows:4. Additional Information. You meet the eligibility requirements, but to determine whether your absence qualifies as FMLA leave, you must return the following information by _____________________ (date at least 15 calendar days after notice is provided to employee). If sufficient information is not timely provided, your leave may be denied.  FORMCHECKBOX  Sufficient certification to support your request for FMLA leave. The enclosed certification form must be returned.  FORMCHECKBOX  Sufficient documentation to establish the required relationship between you and your relative.  FORMCHECKBOX  No additional information is requested.  FORMCHECKBOX  Other information. (Explain information needed.)  FORMTEXT       5. Paid Leave Substitution. We  FORMCHECKBOX  will or  FORMCHECKBOX  will not require that you substitute accrued paid leave for unpaid FMLA leave. You have the right to elect to substitute accrued paid leave for unpaid FMLA leave as provided in your collective bargaining agreement or the civil service rules and regulations. If you do not meet the conditions for taking paid leave, you remain entitled to take unpaid FMLA leave. Any paid leave used counts against your FMLA leave entitlement. The following conditions will apply: (Explain any conditions.)  FORMTEXT       6. Insurances. To retain your health, dental, and vision insurance coverage during an unpaid FMLA leave, you must pay any required employee share of the biweekly insurance premiums. You may be required to repay the share of premiums paid by the department to retain your coverage if you do not return to employment after a FMLA-designated unpaid leave for reasons other than continuation, recurrence, or onset of a serious health condition or a covered servicemembers injury or illness or for other circumstances beyond your control.  FORMCHECKBOX  You have a 30-day grace period to make premium payments once you go off the payroll. You must make arrangements to pay your biweekly share of insurance premiums with your HR office. If not timely paid, your coverage will be canceled 15 days after we send written notice that your coverage will lapse.  FORMCHECKBOX  We will continue coverage and recover your share of insurance premiums from you upon your return to work.7. Key Employee. You  FORMCHECKBOX  are or  FORMCHECKBOX  are not a key employee, whose restoration to employment may be denied after FMLA leave, as authorized under the FMLA, because we have determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm.8. Periodic Reports. While on leave, you  FORMCHECKBOX  will or  FORMCHECKBOX  will not be required to furnish us with periodic reports every ______________ (indicate interval, as appropriate for particular situation) of your status and intent to return to work. 9. This eligibility form was provided to the employee on ______________ (date) by ___________________________ (name) by:  FORMCHECKBOX  Personal delivery  FORMCHECKBOX  First-class mail  F7;DFmn M N Z v x z F H    " ˼~w~pia~Uhh|<mH nH uhhG5 hh hh] hh ^ hh!09 hh7^ hh|< hh^ahh7^CJaJhh7^5hh^a59:CJaJhh7^59:CJaJhh|<9:hh7^9:hhCVmH nH uhhCVCJjhhCVU3 M }tk__ $$Ifa$gd7^ $Ifgd7^ $Ifgdbkd$$IflF~ J( (    4 laytG l $IfgdCV $Ifgd7^ $IfgddM N   '^kd$$Ifl.((   0(4 la ($Ifgd% <($Ifgd%`kds$$IflL.((    0(4 la" - 2 3 = >  > @ T V d f l 糫zrbzVFjhhD>U\hhVmH nH ujhhU\hh\jhhU\hhmH nH uhhV\j/hhD>U\hhD>\jhhD>U\ hhVjhhD>U hhD>jhhD>Uhh|<mH nH uhh84>mH nH u 2  > f @kd$$IflF .(     0(    4 la  $Ifgd|< $IfgdD>  $Ifgd|< $Ifgdi  $Ifgd|< 2 \ xGkd$$IflF .(     0(    4 la  $Ifgd|<  $Ifgd $Ifgdi  $IfgdV 0 2 6 8 \ d f l n &(<>HRϼyk]j{hhD>UjhhD>UjhhD>UjhhD>UjhhD>U hhD>jhhD>U hhi hhVhh|<mH nH uhhVmH nH uhh4?\mH nH uhh\mH nH uhhV\$RThjvx,.0DFTV|ѸѪќƒ؆zmeUmMhh5j hhU\hh\jhhU\hh7^mH nH uhhmH nH uhh7^5\jmhh7^Ujhh7^Ujuhh7^Ujhh7^U hh7^ hhVjhhD>U hhD>jhhD>U.V~:n,B$If^`Bgd $Ifgd7^  $Ifgd7^ $If^gd  $IfgdV $Ifgd  $IfgdV|~:FH\^lvx󍂍tfXj hh7^UjU hh7^Uj hh7^Ujhh7^U hh7^)jQ hh5UmH nH u)j hh5UmH nH u)jY hh5UmH nH u#jhh5UmH nH uhh5mH nH uhh7^mH nH u!*.2hjl()789destu}~@DExphhJ>* hhJjhh7^Uj hh7^Ujhh7^Uj%hh7^Ujhh7^Uj=hh7^Ujhh7^Uhh L5\hh7^5\ hh7^ hh',.j( UulccZMcc  & F $IfgdJ $Ifgd4? $Ifgd $IfgdkdO $$IfleF .(     0(    4 laytJEFPQ  68:ƾtfttXttjmhh7^Ujhh7^Ujhh7^U!johh>*U\hh>*\jhh>*U\hh\ hhJ hh7^hhJ6hh6hhJ>*!jhhJ>*U\hhJ>*\jhhJ>*U\*+,78FGHTUVߵߧߙߋ{qha hhJhhJaJhhJ5\hh7^5B*\aJphjhh7^Uj%hh7^Ujhh7^Uj=hh7^Ujhh7^UjUhh7^U hh7^jhh7^Ujhh7^U&UVvvfvW($*$IfgdJd8$IfgdJdL$IfgdJdL($IfgdJ dL$IfgdJ^kd $$Ifl.((  0(4 la(,<>Z\^`fhj :<>RzjhhB@UhhJ\!jhhJ5>*UjhhJU!jhhJ5>*UjhhJ5>*UjhhJUjhhJU hhJhhJ5hhJ5>*0RT^d $&$&02ټٮϝǏټفph`hhJ\hhJ>*!jhhJ5>*UjkhhJUhhJ56CJaJ!jhhJ5>*Uj{hhJUjhhJUhhJ5hhJ5>* hhJjhhJ5>*U!jhhJ5>*U%2#qa$(($Ifa$gdJ^kd[$$Ifl.((  0(4 lad`($*$IfgdJ ($IfgdJdL($*$IfgdJ#$ " [ w { ! !!!/!0!1!]!!!!!ܻ~p~g]g]hhJ6aJhhJaJjihhJUjhhJUhh56\hh5\hhJ5\ hhw hhw mH nH uhhw 5\hhG>*CJaJhhGCJaJhhw CJaJhhJ5aJhhJ5 hhJ$#$,ckd$$Ifl@.((  0(4 layt ($IfgdJckd$$Ifl.((  0(4 laytJ ]G$$$If^`a$gdGvkd]$$Ifl0J.(    0(4 laytGh($If^hgdJ ($IfgdJ$If^`gdJ r  $Ifgdw $$Ifa$gdw   $Ifgdw akd=$$Ifl.(( 0(4 layt !"#$$pg^^ $Ifgd $Ifgdov$If^v`gd] $Ifgdtkd$$Ifl0.(0(4 laytw !!!"""" 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This designation will be accomplished by reissuing this form to you with Section III below filled in.Section III Designation of FMLA Leave Completed by employer after receiving certificationWe have received your most recent information on _____________(date) and decided as follows:1.  FORMCHECKBOX  Your requested leave is approved from (date) ___________ to (date) ___________. All leave taken will count against your FMLA entitlement. Please see Section II, #5 above for information on paid leave substitution and your FMLA leave.  FORMCHECKBOX  The certification you provided is insufficient to determine your eligibility. By ______________ (date at least 7 calendar days after notice provided to employee), you must provide the following or your leave may be denied: (Explain what information is needed to make the certification complete and sufficient below.)  FORMCHECKBOX  We are requiring an additional medical certification at our expense and will provide further details later.  FORMCHECKBOX  Your requested leave does not meet the requirements for FMLA leave. (Explain why below.)  FORMTEXT      2. You  FORMCHECKBOX  will or  FORMCHECKBOX  will not be required to furnish recertification relating to a serious health condition. (Explain below, including the interval between certifications. See 825.308 of the FMLA regulations for conditions.)  FORMTEXT      3.  FORMCHECKBOX  If your anticipated leave schedule does not change, _____________ will count against your FMLA entitlement.  FORMCHECKBOX  It is not possible to calculate how much leave will count against your FMLA entitlement now. You have the right to request this information once every 30 days from your HR office (if leave was taken during the 30 days).4. You  FORMCHECKBOX  will or  FORMCHECKBOX  will not be required to present a fitness-for-duty certificate before being restored to employment. If a required certification is not received, your return to work may be delayed until it is provided. 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