Policy Manual sample

MDT Home Health Care Agency, Inc. FAMILY/MEDICAL LEAVE OF ABSENCE REQUEST FORM Name: ___________________________________________ Date: ___________________ Date of Hire: _____________________________ Eligibility Date: ______________________ (To be completed by Employee) I request a leave of absence beginning on/about _________________. If this request is granted, I currently expect to return to work on _______________. I will notify my Supervisor if there is a change with these dates. I need a leave of absence for the following reason: CHECK APPLICABLE REASON ________ A serious medical condition which makes me unable to perform the duties of my job. ________ To care for my spouse, child or parent who has a serious medical condition. ________ The birth of my child. (Note: The Employee is responsible for contacting the Human Resource Department in order to have a new child added on to Health Insurance within two weeks of birth.) _________ The adoption or foster care of a child. I have read and understand MDT Home Health Care Agency, Inc.’s family medical leave of absence policy and procedure. I understand that I must pay in advance my monthly payroll deduction portion of the premium of the health/dental insurance plan while on leave. I understand that payment must be received by the end of the first week of each month in the human resource department in order to continue my health/dental insurance. I understand that MDT Home Health Care Agency, Inc. requires medical certification substantiating a serious medical condition and that I will be required to provide medical certification within 15 days of the request. Failure to provide timely certification may result in the denial of leave until proper certification is received. I also understand that MDT Home Health Care Agency, Inc. will require reports every 30 days concerning my status and a fitness-for- duty medical certification as a condition of, and prior to, my returning from leave. I also understand that, if I do not return to work or contact my supervisor by the expected date of return, I will be considered to have abandoned my job. I understand if I choose to not return to work for reasons other than a continued serious health condition, MDT Home Health Care Agency, Inc. will require me to reimburse the total amount paid for my health insurance premium during the leave period. I understand that I shall be required to use accrued paid time off (pto) for all or a portion of the leave. I further understand, that I will be placed on inactive payroll status if I am unable to return to work once I have exhausted the annual leave. _______________________________________________ _______________________ Employee Signature Date _______________________________________________ _______________________ Director’s Signature Date Home Health Agency. - - Personnel/Operations Policies B-137