[{"id":"e54846a8-063e-45e1-939c-bf3962aeb5e1","order":1,"text":"FAMILY AND MEDICAL LEAVE ACT","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"f02a770e-e003-4957-9610-ecab32307edd","order":2,"text":"LEAVE REQUEST, NOTICE OF ELIGIBILITY, NOTICE OF RIGHTS AND RESPONSIBILITIES AND DESIGNATION NOTICE","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"d2582775-a435-49ef-a64f-4d62e62b7fc4","order":3,"text":"LEAVE REQUEST AND NOTICE OF ELIGIBILITY","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}]},{"id":"9af27f08-bff5-493c-a7d5-beaa156c032a","order":4,"text":"Issued under the Family and Medical Leave Act of 1993, 29 U.S.C. § 2601 et seq., and the implementing regulations of the Secretary of Labor at 29 C.F.R. Part 825","fontSize":"12","textAlign":"center","bold":false,"underline":false,"marginBottom":"25","cflou":false,"active":true},{"id":"46d18464-7f44-4fe9-a622-d0cbc1104b3e","order":5,"text":"THE EMPLOYER","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"7a871d2f-c81d-448f-af75-6bc035be3ccb","order":6,"text":"Name: [Employer legal name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"3","cflou":false,"active":true},{"id":"8f7edc88-2861-4fb5-a1b7-f0b906c5736b","order":7,"text":"Address: [Street address], [City, State and ZIP code]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"3","cflou":false,"active":true},{"id":"05c76d28-aa87-4d47-83e5-c4e5c0ae3cb1","order":8,"text":"Telephone: [Telephone number]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"18","cflou":false,"active":true},{"id":"73660202-d5fb-4d7d-9a38-676e9870bf0c","order":9,"text":"THE EMPLOYEE","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"7712c99e-f67c-4e10-aa45-c09897ce3344","order":10,"text":"Name: [Employee full name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"3","cflou":false,"active":true},{"id":"df7207fa-7079-4acd-a651-75238074300e","order":11,"text":"Position: [Job title]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"3","cflou":false,"active":true},{"id":"4ebd8739-5237-4b61-adc5-f98038db0472","order":12,"text":"Employee identification number: [Employee or payroll number]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"3","cflou":false,"active":true},{"id":"e2a93575-420c-4d1e-9071-737700376f66","order":13,"text":"Address: [Street address], [City, State and ZIP code]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"3","cflou":false,"active":true},{"id":"f2f03f2d-ae4a-48f1-a83e-f199747b9814","order":14,"text":"Date of this packet: [Date]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"25","cflou":false,"active":true},{"id":"e9b30672-a77e-4775-89cc-169484f715df","order":15,"text":"PRELIMINARY STATEMENT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true},{"id":"bfdb44aa-233f-41d2-800b-02ed43b764d2","order":16,"text":"This packet is issued by [Employer legal name] (the Employer) to [Employee full name] (the Employee) in connection with the Employee's request for leave under the Family and Medical Leave Act. It brings together, in a single instrument, the documents that the FMLA and its implementing regulations require to be exchanged when an employee requests leave that may be FMLA-qualifying.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"04295940-c265-4070-8f55-b995c67dbe5b","order":17,"text":"— Part I contains the Employee's written request for leave and the information the Employee is required to give under 29 C.F.R. §§ 825.302 and 825.303.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"8bb2c2a1-aa1b-40bd-8179-172851010f99","order":18,"text":"— Part II contains the notice of eligibility required by 29 C.F.R. § 825.300(b).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"eacfdc28-da46-4725-b196-4e5c97748e1a","order":19,"text":"— Part III contains the notice of rights and responsibilities required by 29 C.F.R. § 825.300(c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"4c63bf10-4f0d-43bd-84e6-3f57bb02d222","order":20,"text":"— Part IV contains the designation notice required by 29 C.F.R. § 825.300(d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"8f5599dc-9e96-43ad-9676-5207b7c6db1f","order":21,"text":"— Part V contains provisions of general application.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"0afa3ded-7c3e-437e-b3f1-66dcfd2b4df0","order":22,"text":"The completion of this packet does not itself grant, deny or extend leave. Each determination made by the Employer is stated in the Part to which it relates.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7e7f0e01-3437-460d-be4c-a1dd7e3c8419","order":23,"text":"1. DEFINITIONS AND CONSTRUCTION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S01"},{"id":"75b5d150-a334-47d9-a3ee-d247f587b3c5","order":24,"text":"FMLA means the Family and Medical Leave Act of 1993, as amended, together with the regulations of the Secretary of Labor at 29 C.F.R. Part 825.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"28700dce-cb24-406f-ba83-5c0aac3af7ef","order":25,"text":"Covered employer means an employer that employs 50 or more employees for each working day during each of 20 or more calendar workweeks in the current or preceding calendar year, as provided at 29 C.F.R. § 825.104.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8820d7e9-8b02-4723-a3a6-cd9166d6349e","order":26,"text":"Eligible employee means an employee who has been employed by an employer for at least 12 months, who has worked at least 1,250 hours of service during the 12-month period immediately preceding the commencement of the leave, and who is employed at a worksite where that employer employs 50 or more employees within 75 miles of that worksite, as provided at 29 C.F.R. § 825.110. The 12 months of employment need not be consecutive, and, subject to the exceptions stated in that provision, employment preceding a break in service of seven years or more need not be counted.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e9d2088f-8107-4ff1-a94f-995738301488","order":27,"text":"Serious health condition means an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider within the meaning of 29 C.F.R. §§ 825.113 through 825.115.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e59fadab-07b1-485b-8a81-10f97911b53f","order":28,"text":"Covered servicemember, serious injury or illness, covered active duty and qualifying exigency bear the meanings given to them at 29 C.F.R. §§ 825.122, 825.126 and 825.127.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"03ef9198-60e1-413f-87e7-7e8c905dfd14","order":29,"text":"Spouse, parent, son or daughter, next of kin and in loco parentis bear the meanings given to them at 29 C.F.R. § 825.122, the term spouse being determined by reference to the law of the place in which the marriage was entered into.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"19bd4d17-c437-424b-84e3-904e7798eaf4","order":30,"text":"Health care provider bears the meaning given at 29 C.F.R. § 825.125, which includes doctors of medicine or osteopathy authorized to practice in the State in which they practice and the other providers listed in that provision, whether practicing in the United States or elsewhere.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"15b4a9a7-fbd4-4ea8-b980-5ea0b47f2488","order":31,"text":"Workweek means the Employee's normal workweek. A workweek of FMLA leave is measured by reference to that normal workweek, and leave taken in periods shorter than a workweek is counted only in the amount actually taken.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ff028666-3f53-4b59-834c-66e8c7ae8ef9","order":32,"text":"Headings are inserted for convenience only. Where this packet refers to another provision of this packet, it does so by the title of that provision and not by its number, since provisions that do not apply are omitted and the remaining provisions are renumbered accordingly.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"db90d441-c9c7-400f-9b3c-23180358e3a2","order":33,"text":"Nothing in this packet diminishes any greater right conferred on the Employee by an applicable State or local law, by a collective bargaining agreement or by an employee benefit plan, as provided at 29 C.F.R. § 825.700.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5c6a03e6-2b37-44b4-8dde-6cf1618676f7","order":34,"text":"PART I — REQUEST FOR LEAVE UNDER THE FAMILY AND MEDICAL LEAVE ACT","fontSize":"16","textAlign":"center","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"marginTop":"25"},{"id":"c7aef82d-421b-421e-b4d5-49a9e24883ec","order":35,"text":"This Part is completed by the Employee. The information given in it constitutes the notice of the need for leave required by 29 C.F.R. §§ 825.302 and 825.303.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"406ceca4-a4a8-4679-a41b-570586204c4d","order":36,"text":"2. EMPLOYEE AND POSITION INFORMATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S02"},{"id":"4bf0834c-a03e-40db-a9ba-74e00eeb5759","order":37,"text":"The Employee, [Employee full name], has been employed by the Employer since [Date of hire], holds the position of [Job title] and is normally scheduled to work [Hours] hours in each workweek.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"75ba8f15-8ddd-421f-8b81-7ff4721ea7d8","order":38,"text":"The Employee's payroll identification number is [Employee or payroll number] and the Employee's address of record is [Street address], [City, State and ZIP code].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"1f58329b-57d1-49e1-a5fe-011d5262c775","order":39,"text":"The Employee works at, or reports to, the worksite of the Employer located at [Street address], [City, State and ZIP code].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"04d91d02-ba44-4838-b6fd-72c81f6bb37a","order":40,"text":"3. REASON FOR THE REQUESTED LEAVE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S03"},{"id":"851b3e11-e5f8-4c6c-a8b5-415afcd4146f","order":41,"text":"The Employee requests leave under the FMLA for the following reason: the Employee's own serious health condition.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"60eab3c1-0017-45ae-88a5-e0ce3b0e2164","order":42,"text":"The leave concerns the Employee's spouse, [Full name of the person concerned].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"add","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"add","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"add","operator":"="}]},{"id":"1a89a2d5-7af7-45aa-a3f6-95301e0e88c6","order":43,"text":"The Employee states that the condition makes the Employee unable to perform one or more of the essential functions of the Employee's position.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"add","operator":"="}]},{"id":"144570fb-c60b-4b5b-9996-93e81280696a","order":44,"text":"Leave taken for the birth of a child and to care for the newborn child must be concluded within 12 months of the date of birth, as provided at 29 C.F.R. § 825.120.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"add","operator":"="}]},{"id":"109b1e22-2cbc-43f8-8afa-3034093f0bff","order":45,"text":"Leave may also be taken before the birth, for prenatal care or where the Employee is incapacitated by pregnancy, and either parent is entitled to leave for the birth of the child, as provided at 29 C.F.R. § 825.120.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"add","operator":"="}]},{"id":"790d8893-1d77-4cc7-be7b-cfacd6ce1a88","order":46,"text":"Leave taken for the placement of a child for adoption or foster care must be concluded within 12 months of the date of placement, and leave may also be taken before the placement where an absence is required for the placement to proceed, as provided at 29 C.F.R. § 825.121.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"add","operator":"="}]},{"id":"5c6774f0-708c-429d-b322-1f3ea97ce881","order":47,"text":"Absences of that kind include attending counseling sessions, appearing in court, consulting an attorney or a doctor representing the birth parent, and traveling to another country to complete the adoption.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"add","operator":"="}]},{"id":"4471d887-fb37-44ec-bc67-a075ef808ad7","order":48,"text":"Qualifying exigency leave is available only for the categories of exigency listed at 29 C.F.R. § 825.126, and the military member concerned must be on covered active duty or called to covered active duty status.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"add","operator":"="}]},{"id":"2dd3f59c-e44d-41f3-b27d-fe7a974ed89d","order":49,"text":"Those categories are short-notice deployment, military events and related activities, childcare and school activities, care of the military member's parent, financial and legal arrangements, counseling, rest and recuperation, post-deployment activities, and any additional activity agreed between the Employer and the Employee. Leave for rest and recuperation is limited to the period of leave granted to the military member, up to 15 calendar days.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"add","operator":"="}]},{"id":"fb88cc33-5f73-4b3a-8376-32bb8f78a1c8","order":50,"text":"Military caregiver leave is available only where the Employee is the spouse, son, daughter, parent or next of kin of the covered servicemember and the injury or illness is a serious injury or illness within the meaning of 29 C.F.R. § 825.127.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"add","operator":"="}]},{"id":"2d1f8d47-5f29-488f-b43c-552496cc4c99","order":51,"text":"The Employee acknowledges that the Employer may require reasonable documentation or a statement of the family relationship relied upon, as permitted by 29 C.F.R. § 825.122(k).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="}]},{"id":"d97f3a32-553a-4722-9dee-5db2fe78f8d1","order":52,"text":"4. DATES AND EXPECTED DURATION OF THE LEAVE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S04"},{"id":"4f2a689b-19b7-4f15-9081-2992317a2746","order":53,"text":"The Employee gave notice of the need for leave on [Date notice given], at least 30 calendar days in advance of the first day of leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"2e1c5b6d-156b-4e55-8e48-f4992cfaa149","order":54,"text":"The first day of the requested leave is [Start date] and the Employee anticipates returning to work on [Anticipated return date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"34bf9345-f86c-456d-aa24-1f2b79850b47","order":55,"text":"Where the need for leave is foreseeable, notice must be given at least 30 days in advance or, if that is not practicable, as soon as practicable, as provided at 29 C.F.R. § 825.302. Where the need for leave is unforeseeable, notice must be given as soon as practicable, which will generally be the same or the next business day after the need for leave becomes known, as provided at 29 C.F.R. § 825.303.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7131070d-ed9f-42e7-99a4-3a39abd244e4","order":56,"text":"The Employee will give sufficient information for the Employer to determine whether the leave may be FMLA-qualifying and the anticipated timing and duration of the leave. Calling in sick, without more, does not constitute sufficient notice.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"095b7393-b830-4429-8813-4a125b08ab6f","order":57,"text":"5. REQUESTED LEAVE SCHEDULE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S05"},{"id":"e95a646a-25f3-478e-b071-5e234133032c","order":58,"text":"The Employee requests continuous leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5ece1ba8-6763-4144-bd4a-f7d8e6b2206f","order":59,"text":"The Employee will be absent for a single uninterrupted period beginning on the first day of leave and ending on the anticipated date of return stated in the provision of this packet entitled DATES AND EXPECTED DURATION OF THE LEAVE.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"continuous leave","type":"add","operator":"="}]},{"id":"45c74f8a-93e9-481b-b49c-058519c838ac","order":60,"text":"The Employee expects the absences to occur with the following frequency and duration: [Frequency and duration].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="}]},{"id":"24f211bb-90c2-4bc6-a9e4-6544b13dc860","order":61,"text":"The reduced leave schedule requested is the following: [Reduced schedule requested].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="}]},{"id":"8b16a457-ffd7-47c9-a7b9-7383d5c78120","order":62,"text":"Leave taken intermittently or on a reduced leave schedule for the birth or placement of a child is available only where the Employer agrees. In all other cases such leave is available where it is medically necessary or, for qualifying exigency leave, where the exigency so requires, as provided at 29 C.F.R. §§ 825.202 and 825.203.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="}]},{"id":"79ff1ffd-060d-4b9f-ae96-098e283bb581","order":63,"text":"Where the leave is foreseeable and based on planned medical treatment, the Employee will make a reasonable effort to schedule the treatment so as not to disrupt unduly the operations of the Employer, subject to the approval of the health care provider concerned.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="}]},{"id":"e345efa2-e213-4fae-9933-50a525c1da40","order":64,"text":"6. EMPLOYEE NOTICE AND REPORTING UNDERTAKINGS","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S06"},{"id":"aa6556da-145a-4bf9-8b1c-b228606b6603","order":65,"text":"The Employee will comply with the Employer's usual and customary notice and procedural requirements for reporting an absence, unless unusual circumstances prevent compliance, as provided at 29 C.F.R. § 825.303(c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"79ccdfa0-5d70-4803-8e97-ae3a2468560e","order":66,"text":"The Employee will furnish any certification requested by the Employer within the time allowed by this packet and will inform the Employer promptly of any change in the anticipated dates, frequency or duration of the leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f51e275f-ab5d-4eb8-9ffb-195f6d018505","order":67,"text":"The Employee will report periodically to the Employer on the Employee's status and intention to return to work, as provided at 29 C.F.R. § 825.311.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"131d67eb-857d-492b-a631-7eee0c5d306b","order":68,"text":"The Employee acknowledges that a failure to give the required notice, or to furnish a requested certification, may result in the delay or the denial of FMLA protection for the leave, as provided at 29 C.F.R. §§ 825.304 and 825.313.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"353f7394-3a5c-432f-9a34-fec5fe9afb42","order":69,"text":"7. EMPLOYEE STATEMENT, AUTHORIZATION AND SIGNATURE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S07"},{"id":"c5dee466-37c9-4ac1-8181-9a3bdf3ffb31","order":70,"text":"The Employee states that the information given in this Part is true and complete to the best of the Employee's knowledge and belief.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e70a4fff-1bec-4841-b258-834c94cbad8d","order":71,"text":"The Employee authorizes the Employer to use that information solely for the administration of the Employee's leave and to disclose it only to the extent permitted by 29 C.F.R. § 825.500(g) and by applicable law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"4881304c-a5b6-4728-a825-16f86c31dcc0","order":72,"text":"The Employee understands that a request for leave is not itself a designation of leave as FMLA leave, and that the Employer will notify the Employee of its determinations in the Parts of this packet that follow.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5528b1a3-293f-4bc1-9335-ac0a22567e2f","order":73,"text":"Signature of the Employee: ______________________________ Date: ____________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"69362442-d9fe-48fa-be90-e4d7bf038225","order":74,"text":"PART II — NOTICE OF ELIGIBILITY","fontSize":"16","textAlign":"center","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"marginTop":"25"},{"id":"6af44f92-905b-421b-a4b4-3494663f9e42","order":75,"text":"This Part is completed by the Employer. It constitutes the notice of eligibility required by 29 C.F.R. § 825.300(b), which must be given within five business days of the Employee's request for leave, or of the Employer becoming aware that the leave may be FMLA-qualifying, absent extenuating circumstances.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"25716598-0ae5-4624-95f4-b1762232821f","order":76,"text":"8. ELIGIBILITY REQUIREMENTS UNDER THE FMLA","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S08"},{"id":"e77d2aff-1f75-4938-8694-54df2c8fe010","order":77,"text":"To be eligible for leave under the FMLA an employee must have been employed by an employer for at least 12 months, must have worked at least 1,250 hours of service during the 12-month period immediately preceding the commencement of the leave, and must be employed at a worksite where that employer employs 50 or more employees within 75 miles of that worksite.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cf36d6fd-9d0e-4df8-9a57-479702f50048","order":78,"text":"Where an employee has been absent because of service covered by the Uniformed Services Employment and Reemployment Rights Act, the months of employment and the hours that would have been worked during that absence are counted toward these requirements, as provided at 29 C.F.R. § 825.110(b)(2)(i) and (c)(2).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5e220b00-05a9-4292-8b68-20833be61f63","order":79,"text":"Hours of service are determined according to the principles established under the Fair Labor Standards Act for ascertaining compensable hours of work, as provided at 29 C.F.R. § 825.110(c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c40f46d0-2463-4737-95f5-eda258ea29b4","order":80,"text":"An eligible employee is entitled to a total of 12 workweeks of leave during the applicable 12-month period for one or more of the reasons stated at 29 U.S.C. § 2612(a)(1), and to a total of 26 workweeks of leave during a single 12-month period to care for a covered servicemember, as provided at 29 U.S.C. § 2612(a)(3) and 29 C.F.R. § 825.127.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"2a2be663-0a40-4407-aa42-5da79fdfee29","order":81,"text":"Eligibility is determined as of the date on which the leave commences. Once an employee has been notified of eligibility, that determination governs the leave for which it was given.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"09e83765-f512-4ff3-9458-3f9e799c548e","order":82,"text":"9. ELIGIBILITY DETERMINATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S09"},{"id":"da7a966f-9f7c-4fc4-ac98-3e7ab65b8539","order":83,"text":"Having examined the Employee's period of employment, hours of service and worksite, the Employer determines that the Employee IS ELIGIBLE for leave under the FMLA in respect of the leave described in Part I.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"eligible","type":"add","operator":"="}]},{"id":"9ed58230-da7d-4010-894e-63d0b0a4c7b2","order":84,"text":"If the Employee's eligibility status changes, the Employer will notify the Employee of the change and of the reason for it.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"eligible","type":"add","operator":"="}]},{"id":"451aafbe-53f8-40db-a3af-67f2525e26b2","order":85,"text":"Having examined the Employee's period of employment, hours of service and worksite, the Employer determines that the Employee IS NOT ELIGIBLE for leave under the FMLA in respect of the leave described in Part I.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}]},{"id":"da81a8fc-5e69-4c6b-92d7-9f62d65d8d4d","order":86,"text":"The reason for this determination is that the Employee has not been employed by the Employer for at least 12 months.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}]},{"id":"347f4f53-0faa-49fa-8f65-ec64ab92abc4","order":87,"text":"As of [Start date] the Employee's period of employment with the Employer stood at [Months of employment] and the hours of service worked during the preceding 12-month period stood at [Hours of service].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}]},{"id":"d75c2f77-8dbe-47a9-85e4-4ee6076baaeb","order":88,"text":"Because the Employee is not eligible, no leave is designated as FMLA leave and the rights and responsibilities that attach to FMLA leave do not arise in respect of this request. The Employee may seek leave under any other policy of the Employer, or under any applicable State or local law, and may become eligible for FMLA leave at a later date if the eligibility requirements are then satisfied.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}]},{"id":"840a36ab-7354-4d9c-85b2-79143b8ace79","order":89,"text":"A determination of ineligibility under the FMLA does not dispose of any right the Employee may have under Title VII of the Civil Rights Act of 1964 as amended by the Pregnancy Discrimination Act, under the Americans with Disabilities Act, under a State or local leave law, or under a collective bargaining agreement. An employee employed for less than 12 months may not be denied maternity leave where the Employer normally provides short-term disability benefits to employees, as provided at 29 C.F.R. § 825.702(f).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}]},{"id":"02ec018e-9b61-49f5-a257-fcf6b533baea","order":90,"text":"The Employee may ask for an explanation of this determination by contacting the person identified in the provision of this packet entitled QUESTIONS AND CONTACT INFORMATION.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3a0f6b51-2af0-489a-a41d-4751dea0b621","order":91,"text":"PART V — GENERAL PROVISIONS","fontSize":"16","textAlign":"center","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"add","operator":"="}],"marginTop":"25"},{"id":"533f2910-d9e4-480c-846b-60c7f55758cc","order":92,"text":"PART III — NOTICE OF RIGHTS AND RESPONSIBILITIES","fontSize":"16","textAlign":"center","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"25"},{"id":"e9525a7c-c156-44e1-891e-8008bb570a89","order":93,"text":"This Part constitutes the written notice of rights and responsibilities required by 29 C.F.R. § 825.300(c). It is given at the same time as the notice of eligibility and states the obligations of the Employee and the consequences of a failure to meet them.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"5918b1a9-b560-4f8f-bf85-83b896e01899","order":94,"text":"If any of the information given in this Part changes, the Employer will give the Employee written notice of the change within five business days of the Employee's first notice of the need for leave given after the change, referring to this notice and stating what has changed.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"d2f2acc1-8c40-4c8b-8456-fb78f03faca2","order":95,"text":"10. AMOUNT OF FMLA LEAVE AVAILABLE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S10"},{"id":"42b81a6c-09b9-431e-a6af-a4661b36fab5","order":96,"text":"The Employee is entitled to 12 workweeks of FMLA leave during the applicable 12-month period.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"c3197a8c-d5f4-47ad-9eb5-b9e20b3b1a02","order":97,"text":"Because the leave is to care for a covered servicemember, the Employee is entitled to 26 workweeks of leave during a single 12-month period beginning on the first day of leave taken for that purpose. During that single 12-month period the Employee is entitled to a combined total of 26 workweeks of leave for all FMLA-qualifying reasons, of which no more than 12 workweeks may be taken for a reason other than to care for a covered servicemember.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"add","operator":"="}]},{"id":"8bbe3490-4692-4332-aa72-b58fad93939e","order":98,"text":"The records of the Employer show that the Employee has previously used the following amount of FMLA leave in the applicable 12-month period: [Amount already used].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"fe4b3b4e-8934-48e9-bc79-93b8e8cf486a","order":99,"text":"Where a holiday falls within a week taken in its entirety as FMLA leave, the whole week is counted as a week of FMLA leave. Where leave is taken in increments of less than a week, a holiday is not counted against the entitlement unless the Employee was otherwise scheduled and expected to work on that day, as provided at 29 C.F.R. § 825.200(h).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"5baedbe3-2434-4f02-8833-dbe235b89e1e","order":100,"text":"Leave is counted in increments no greater than the shortest period that the payroll system of the Employer uses to account for absences, and in no case greater than one hour, as provided at 29 C.F.R. § 825.205.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"b1b70587-7fee-4465-bc2e-3cfc7ff2d826","order":101,"text":"Where the Employee and the Employee's spouse are both employed by the Employer, the FMLA limits the aggregate amount of leave that the two may take for the birth or placement of a child, to care for a parent with a serious health condition, and to care for a covered servicemember, as provided at 29 C.F.R. §§ 825.120, 825.201 and 825.127.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"db83b564-e217-4c6b-ad95-0ab8ef745540","order":102,"text":"11. THE APPLICABLE 12-MONTH PERIOD","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S11"},{"id":"60f003e5-c0ca-46b7-87ab-07869ab405f8","order":103,"text":"The Employer determines the 12-month period in which the leave entitlement arises by reference to the calendar year, running from January 1 through December 31.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"111682b2-fc99-4239-89fc-3454f8884d75","order":104,"text":"This method is applied uniformly to all employees. Where an employer fails to select a method, the method that provides the most beneficial outcome to employees is used, as provided at 29 C.F.R. § 825.200(e). The Employer will give at least 60 days' notice before changing the method.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"ef8a9803-31f4-4e6f-a33b-d1f9e21832bb","order":105,"text":"The single 12-month period applicable to leave taken to care for a covered servicemember begins on the first day on which such leave is taken and ends 12 months afterwards, whatever the method described above.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"add","operator":"="}]},{"id":"29a76eea-4f0d-4dde-97d8-ebab7436c348","order":106,"text":"12. CERTIFICATION AND SUPPORTING DOCUMENTATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S12"},{"id":"7936ae15-bb2d-4219-bc5d-2f31dbc94f08","order":107,"text":"The Employer requires the Employee to furnish a certification in support of the requested leave, as permitted by 29 C.F.R. § 825.305.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"0d7fbcdf-66ac-4154-ae42-a7daa2d9683d","order":108,"text":"The Employee is required to furnish a certification of the Employee's own serious health condition completed by the Employee's health care provider, the content of the certification being governed by 29 C.F.R. § 825.306. Form WH-380-E published by the United States Department of Labor may be used for that purpose.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"5f88b042-84d2-45d3-acd4-b7a4ad0042aa","order":109,"text":"The Employee is required to furnish a certification completed by the health care provider of the family member for whom care will be provided, the content of the certification being governed by 29 C.F.R. § 825.306. Form WH-380-F published by the United States Department of Labor may be used for that purpose.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"b8e98ca6-583c-4de5-93c6-7c0f8b0babba","order":110,"text":"The Employee is required to furnish a certification of qualifying exigency together with a copy of the covered military member's active duty orders or other documentation issued by the military, as provided at 29 C.F.R. § 825.309. Form WH-384 published by the United States Department of Labor may be used for that purpose.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"6e9c811c-b0ff-43a4-b246-3069d7d87813","order":111,"text":"The Employee is required to furnish a certification for military caregiver leave completed by an authorized health care provider, or, in the alternative, an invitational travel order or invitational travel authorization, as provided at 29 C.F.R. § 825.310. Forms WH-385 and WH-385-V published by the United States Department of Labor may be used for that purpose.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="}]},{"id":"8fe6e7f5-2761-4ff3-9437-367b53404e0b","order":112,"text":"The Employee is required to furnish reasonable documentation confirming the birth of the child and the family relationship relied upon, as permitted by 29 C.F.R. § 825.122(k).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"2f5b0750-0e48-4375-af25-908156e8cf28","order":113,"text":"The Employee is required to furnish reasonable documentation confirming the placement of the child for adoption or foster care and the family relationship relied upon, as permitted by 29 C.F.R. § 825.122(k).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"b9c287dc-f923-406c-8684-aee2f6ffdf7f","order":114,"text":"The certification must reach the Employer by [Date certification is due]. The Employee is allowed at least 15 calendar days from the date of this notice in which to furnish it, as provided at 29 C.F.R. § 825.305(b).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"194bf9e6-fe79-4dc8-b487-5984fdcb9d2c","order":115,"text":"If the certification returned is incomplete or insufficient, the Employer will state in writing what additional information is necessary and will allow the Employee at least seven calendar days to cure the deficiency, as provided at 29 C.F.R. § 825.305(c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"962b66fb-87e5-4e57-ada4-7d741bd40034","order":116,"text":"The Employer may seek authentication or clarification of a medical certification through a health care provider, a human resources professional, a leave administrator or a management official, but never through the Employee's direct supervisor, and will not request information beyond that permitted by the FMLA. Where the Health Insurance Portability and Accountability Act applies, the Employer will comply with its requirements, as provided at 29 C.F.R. § 825.307.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"33db68c1-387e-4eae-af57-8530db79cf29","order":117,"text":"Where the Employer has reason to doubt the validity of a medical certification, it may require, at its own expense, a second opinion from a health care provider that it designates and that it does not regularly employ, and, where the two opinions differ, a binding third opinion from a health care provider approved jointly by the Employer and the Employee, as provided at 29 C.F.R. § 825.307(b) and (c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"f0a08303-4c9a-40d5-bc1b-76a070ac3af6","order":118,"text":"Pending receipt of a second or third opinion the Employee is provisionally entitled to the benefits of the FMLA, including the maintenance of group health benefits. Where the opinions do not ultimately establish the entitlement, the leave will not be designated as FMLA leave and may be treated as paid or unpaid leave under the established leave policies of the Employer, as provided at 29 C.F.R. § 825.307(b).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"94d87602-1da8-44d5-8972-c9de553f72df","order":119,"text":"The Employer may request a recertification in accordance with 29 C.F.R. § 825.308. In every case the Employer may request a recertification in connection with an absence at intervals of at least six months.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"ad2b8137-3d29-4757-b9b5-aa7ed1b7d1ad","order":120,"text":"Where the need for leave lasts beyond a single leave year, the Employer may require a new medical certification in each subsequent leave year, as provided at 29 C.F.R. § 825.305(e). The Employer will not require information beyond that specified in 29 C.F.R. §§ 825.306, 825.307 and 825.308.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"97d5a7c3-32c5-4d32-8a73-46cc259297c7","order":121,"text":"The Employer does not request genetic information. The Employee is asked not to include genetic information, within the meaning of the Genetic Information Nondiscrimination Act of 2008, in any document furnished in response to a request for certification.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"802ab228-4196-451a-bff0-85f1f09ee0d9","order":122,"text":"A failure to furnish a complete and sufficient certification within the time allowed may result in the denial of FMLA protection for the leave, as provided at 29 C.F.R. § 825.313.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fdc8c108-f158-4506-b501-3369fb0f7ffa","value":"required","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"d9a13d05-ccbb-4d9a-8db8-446bbff97cfa","order":123,"text":"13. SUBSTITUTION OF ACCRUED PAID LEAVE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S13"},{"id":"f3305a03-a1ed-46db-93b0-bbda0f07e33c","order":124,"text":"The Employee is required to substitute accrued paid leave for unpaid FMLA leave. The following accrued paid leave applies and runs concurrently with the FMLA leave: [Accrued paid leave that applies].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"ca16aa58-b8ce-4685-8732-130e79e7f458","value":"required","type":"add","operator":"="}]},{"id":"32e08fe5-6252-4b2e-a47f-f68aa66128bf","order":125,"text":"The Employee may elect, but is not required, to substitute accrued paid leave for unpaid FMLA leave. The following accrued paid leave is available for that purpose: [Accrued paid leave that applies].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"ca16aa58-b8ce-4685-8732-130e79e7f458","value":"elective","type":"add","operator":"="}]},{"id":"4cb2ecc0-3017-4382-9106-2618f3196315","order":126,"text":"No accrued paid leave is available for substitution, and the FMLA leave is therefore unpaid.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"ca16aa58-b8ce-4685-8732-130e79e7f458","value":"none","type":"add","operator":"="}]},{"id":"8ffae6ae-e4ce-4e0d-9796-a23823f7305e","order":127,"text":"FMLA leave is unpaid. The substitution of accrued paid leave does not extend the FMLA entitlement, the paid leave and the FMLA leave running concurrently, as provided at 29 C.F.R. § 825.207.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"82931ed4-7c60-42ca-936a-6a144fd3f090","order":128,"text":"Where the Employee receives payments under a disability benefit plan or under a workers' compensation program the leave is not unpaid, and the provisions concerning substitution do not apply. In that case the Employer and the Employee may agree to supplement those payments with accrued paid leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"d22ebcc8-5383-439f-bcb6-27f5d5642d43","order":129,"text":"In order to substitute paid leave the Employee must satisfy the terms and conditions of the applicable paid leave policy. A failure to satisfy them may cause the leave to be unpaid, but does not deprive the Employee of the right to take unpaid FMLA leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"90604bf6-eac0-431f-84c1-a83f5eb9927b","order":130,"text":"14. MAINTENANCE OF GROUP HEALTH PLAN COVERAGE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S14"},{"id":"7c68a54d-7818-41cf-ae2e-4426d72e9ae5","order":131,"text":"During the FMLA leave the Employer will maintain the Employee's coverage under any group health plan on the same terms as if the Employee had continued to work, as provided at 29 C.F.R. § 825.209.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"1ea6bf59-ddc9-4a93-8e1e-3b7d6cdf5e8c","order":132,"text":"The Employee remains responsible for the Employee's share of the premium, which is currently [Employee share of the premium].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"e963100e-c928-43e9-a324-63621a1d8fc5","order":133,"text":"Payment is due as follows: [How and when payment is due].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"5e450dca-9412-452b-baea-7d0a42fe3b5e","order":134,"text":"If a premium payment is more than 30 days late, the Employer may discontinue the coverage, provided that it gives the Employee written notice at least 15 days before the coverage ceases, as provided at 29 C.F.R. § 825.212.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"60f8f51a-3e94-4fdf-9503-990441f6d1d0","order":135,"text":"If the coverage lapses because a premium has not been paid, the Employer will restore the Employee to coverage on the Employee's return on the same terms as applied before the leave, without any qualifying period, physical examination or exclusion of pre-existing conditions.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"ec6af0de-5865-4d17-98ec-c0d1706e73ed","order":136,"text":"If the Employee does not return to work at the end of the leave for a reason other than the continuation, recurrence or onset of a serious health condition, or another circumstance beyond the Employee's control, the Employer may recover the premiums that it paid to maintain the coverage during the unpaid leave, as provided at 29 C.F.R. § 825.213.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"02cfcbfe-43d2-4999-a109-cf043e4d5672","order":137,"text":"The taking of FMLA leave will not cause the loss of any employment benefit accrued before the leave began, as provided at 29 U.S.C. § 2614(a)(2).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"cc79d45e-e8f2-49e4-82f5-a5959cea4dab","order":138,"text":"15. INTERMITTENT LEAVE AND REDUCED LEAVE SCHEDULE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S15"},{"id":"65c2df8a-57ac-49bf-af29-34b177efc185","order":139,"text":"Leave taken intermittently or on a reduced leave schedule is counted against the FMLA entitlement only in the amount actually taken.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"ea2c3396-1f24-474b-8a08-b00ef39b618c","order":140,"text":"Where the leave is foreseeable and based on planned medical treatment, the Employer may require the Employee to transfer temporarily to an available alternative position for which the Employee is qualified, having equivalent pay and benefits and better accommodating recurring periods of leave, as provided at 29 C.F.R. § 825.204.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"8a4066ba-8253-49c5-913a-ca85fe16b5b5","order":141,"text":"A transfer of that kind is temporary. The Employee will be restored to the same or an equivalent position once the need for intermittent leave or for a reduced leave schedule comes to an end.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"bbe7f799-67d4-4bb6-ac7a-93ab2b69465f","order":142,"text":"The Employee will consult the Employer before scheduling planned treatment and will attempt to arrange it so as not to disrupt unduly the operations of the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"intermittent leave","type":"add","operator":"="},{"field":"5678bfdf-9f8d-435a-8d41-0fb3b2bdba10","value":"leave on a reduced leave schedule","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"f020c271-c365-4da2-9f9f-09faf4afc8be","order":143,"text":"16. REPORTING OBLIGATIONS DURING THE LEAVE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S16"},{"id":"2a4a1d5b-4f9e-4355-8cf4-c56f8ddb5e5d","order":144,"text":"The Employee is required to report to the Employer on the Employee's status and intention to return to work with the following frequency: [Frequency of status reports].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"2989a0f5-d447-4e39-ac38-c216658b7e86","order":145,"text":"The usual and customary requirements of the Employer for reporting an absence are the following:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"1b169755-6d1d-4809-98bf-b98b71e3eee0","order":146,"text":"[Call-in procedure]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"84218930-1356-46a5-97dc-83331832722e","order":147,"text":"If the Employee will need leave beyond the period initially approved, the Employee must notify the Employer as soon as practicable and, where the Employer so requests, furnish a recertification.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"27ff3b19-7af0-4c63-91f3-01c26504d064","order":148,"text":"If the Employee gives the Employer unequivocal notice of an intention not to return to work, the obligations of the Employer to maintain group health benefits and to restore the Employee come to an end, as provided at 29 C.F.R. § 825.311(b).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"a837dc2d-acec-4811-b260-e05a0e9bc8aa","order":149,"text":"17. RESTORATION TO EMPLOYMENT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S17"},{"id":"2c3a729c-5a4e-4372-a576-f9cc78d8709b","order":150,"text":"On return from FMLA leave the Employee is entitled to be restored to the same position held when the leave commenced or to an equivalent position with equivalent pay, benefits and other terms and conditions of employment, as provided at 29 U.S.C. § 2614(a) and 29 C.F.R. §§ 825.214 and 825.215.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"dd02b5bc-8cfb-4d1a-a459-438d09882019","order":151,"text":"An equivalent position is one that is virtually identical to the former position in terms of pay, benefits and working conditions, including privileges, perquisites and status, and that involves substantially equivalent skill, effort, responsibility and authority.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"bf9280b4-f841-4afa-8eb5-386a65c9eef8","order":152,"text":"The Employee has no greater right to restoration, or to any other benefit or condition of employment, than if the Employee had been continuously employed during the period of leave, as provided at 29 C.F.R. § 825.216.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"7e2920cf-6571-441b-bffc-a16f8763987d","order":153,"text":"Restoration may be denied where the Employer shows that the Employee would not have been employed at the time restoration is requested, for instance where the position would have been eliminated in a reduction in force or where a fixed-term appointment would have come to an end, as provided at 29 C.F.R. § 825.216(a).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"7cde5739-a961-490a-acd0-0b7a1ccd97f3","order":154,"text":"Where the Employee remains unable to perform an essential function of the position at the end of the leave, the FMLA confers no right to restoration to another position, although the Employer may owe obligations under the Americans with Disabilities Act, under a State leave law or under a workers' compensation law, as provided at 29 C.F.R. § 825.216(c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"b8ad2b67-d784-4fea-9244-d1e61f86ae18","order":155,"text":"The taking of FMLA leave will not be counted against the Employee under any attendance or absence-control policy of the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"afa20b14-b573-447a-9878-bc20282c29ec","order":156,"text":"Where a bonus or other payment is conditioned on the achievement of a specified goal, such as hours worked, production or perfect attendance, and the Employee has not met the goal because of FMLA leave, the payment may be withheld unless it is paid to employees on an equivalent leave status that is not FMLA leave, as provided at 29 C.F.R. § 825.215.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"eda22c1a-0331-4903-bfcb-d84d8255ec8c","order":157,"text":"The Employee may voluntarily accept a light duty assignment while recovering, but may not be required to do so. Acceptance does not waive any prospective right under the FMLA, the time spent on light duty is not counted against the FMLA entitlement, and the right to restoration is held in abeyance during that time, as provided at 29 C.F.R. §§ 825.220(d) and 825.702(d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"c7035dbb-8b69-4381-b368-4780233db47d","order":158,"text":"Any uniformly applied policy of the Employer governing outside or supplemental employment continues to apply during the leave, as provided at 29 C.F.R. § 825.216(e).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"b9405e11-ce20-4e44-9af1-47a7c869f1b5","order":159,"text":"An employee who fraudulently obtains FMLA leave is not protected by the restoration or benefit maintenance provisions of the FMLA, as provided at 29 C.F.R. § 825.216.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"c9311645-67c3-43d7-8f2b-c0773b53c852","order":160,"text":"18. KEY EMPLOYEE STATUS","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S18"},{"id":"08bb0db4-67a9-4d57-a4e1-c7780f1ed4d0","order":161,"text":"The Employer has determined that the Employee is not a key employee within the meaning of 29 C.F.R. § 825.217. The Employee's right to restoration is accordingly not subject to the limitation that applies to key employees.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"34de0a23-b8d1-4805-b1dd-6e3f8985248d","value":"no","type":"add","operator":"="}]},{"id":"b6ab28a7-d1d3-4d5b-8725-6370f55cd567","order":162,"text":"The Employer has determined that the Employee is a key employee within the meaning of 29 C.F.R. § 825.217, being a salaried eligible employee among the highest paid 10 percent of all the employees whom the Employer employs within 75 miles of the Employee's worksite.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"34de0a23-b8d1-4805-b1dd-6e3f8985248d","value":"yes","type":"add","operator":"="}]},{"id":"e5d45705-e0fe-47eb-98c7-91be5be67092","order":163,"text":"Restoration may be denied to a key employee only where the Employer determines that restoration would cause substantial and grievous economic injury to its operations, and only after the Employer has given the Employee written notice of that determination and a reasonable opportunity to return to work, as provided at 29 C.F.R. §§ 825.218 and 825.219.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"34de0a23-b8d1-4805-b1dd-6e3f8985248d","value":"yes","type":"add","operator":"="}]},{"id":"3f932274-93a5-4f2b-bde6-0be57e55f5e7","order":164,"text":"A determination that restoration would cause substantial and grievous economic injury does not bring the Employee's entitlement to FMLA leave to an end. The Employee retains the right to request restoration at the end of the leave, and the Employer will then determine again whether restoration would cause such injury.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"34de0a23-b8d1-4805-b1dd-6e3f8985248d","value":"yes","type":"add","operator":"="}]},{"id":"8e9d0a77-85a6-4d93-8459-d1208f317b03","order":165,"text":"Any determination concerning key employee status will be made in writing and delivered in person or by certified mail.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"b5a84092-22b1-4786-b5bf-26936dd512fa","order":166,"text":"19. FITNESS-FOR-DUTY CERTIFICATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S19"},{"id":"1f33bddb-30af-453f-8c48-8556adce6d33","order":167,"text":"Because this leave is not taken for the Employee's own serious health condition, no fitness-for-duty certification may be required as a condition of the Employee's restoration to employment, as provided at 29 C.F.R. § 825.312(a).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="}]},{"id":"c9c4b906-6124-49b6-bbc8-ad16747ab0f2","order":168,"text":"The Employer does not require a fitness-for-duty certification as a condition of the Employee's restoration to employment.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"25e8b5d9-2d9d-4dc5-8b74-0dc30bcf6951","value":"none","type":"add","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"9d967a89-e110-4e5d-b500-e89ab8ef0fdc","order":169,"text":"The Employer requires the Employee to furnish, as a condition of restoration, a certification from the Employee's health care provider that the Employee is able to resume work. This requirement is applied to the Employee in the same manner as it is applied to other employees returning from leave of a similar nature, as provided at 29 C.F.R. § 825.312(a) and (d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"25e8b5d9-2d9d-4dc5-8b74-0dc30bcf6951","value":"general","type":"add","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"5c865667-fc20-46d1-ab5a-d843652a8ab8","order":170,"text":"The Employer requires the Employee to furnish, as a condition of restoration, a certification from the Employee's health care provider that the Employee is able to resume work and to perform the essential functions of the Employee's position. A list of those essential functions is provided with this packet and the certification must address the Employee's ability to perform them, as provided at 29 C.F.R. § 825.312(b) and (d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"25e8b5d9-2d9d-4dc5-8b74-0dc30bcf6951","value":"essential","type":"add","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"34de71da-309c-451a-9208-93b6f27a4202","order":171,"text":"The Employer may delay restoration to employment until the required certification is furnished, as provided at 29 C.F.R. § 825.312(e). A fitness-for-duty certification may be required only where the leave was taken for the Employee's own serious health condition, may address only the particular condition that caused the need for leave, and, where leave is taken intermittently or on a reduced leave schedule, may be required no more often than once every 30 days and only where reasonable safety concerns exist. No second or third opinion may be required on a fitness-for-duty certification.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"25e8b5d9-2d9d-4dc5-8b74-0dc30bcf6951","value":"none","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"cdef0c80-bdb0-4305-88f5-73d78d4242ae","order":172,"text":"20. CONSEQUENCES OF A FAILURE TO MEET FMLA OBLIGATIONS","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S20"},{"id":"94f3f58e-428a-4815-8958-c386736d44ff","order":173,"text":"Where the Employee fails to give the notice required for foreseeable leave, the Employer may delay or deny FMLA coverage until 30 days after the date on which the Employee gives notice, as provided at 29 C.F.R. § 825.304.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"e7d174d1-5809-4fce-b782-bf7d03b512e3","order":174,"text":"Where the Employee fails to furnish a requested certification within the time allowed, the Employer may deny FMLA protection for the leave until the certification is furnished, and the absence may be treated as unexcused under the attendance policy of the Employer, as provided at 29 C.F.R. § 825.313.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"f7f59dcb-ea7d-49d3-a156-9b4fa43c2356","order":175,"text":"Where the Employer fails to observe the notice requirements of 29 C.F.R. § 825.300, that failure may constitute interference with, restraint of, or denial of the exercise of the Employee's rights under the FMLA, and the Employer may be liable for compensation, for benefits and for such other relief as may be appropriate, as provided at 29 C.F.R. § 825.300(e).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"db0b72e3-eb5a-4aa6-ac2d-a6664de250ea","order":176,"text":"PART IV — DESIGNATION NOTICE","fontSize":"16","textAlign":"center","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"25"},{"id":"462a6716-c1fc-4583-ad6e-97aa0825ce12","order":177,"text":"This Part constitutes the designation notice required by 29 C.F.R. § 825.300(d). The Employer must notify the Employee whether the leave will be designated as FMLA leave within five business days of having enough information to determine whether the leave is FMLA-qualifying, absent extenuating circumstances. Only the Employer, and not the Employee, may designate leave as FMLA leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"cd7ffd4f-acb4-4a9a-8a18-a10371fbd09e","order":178,"text":"21. DESIGNATION DETERMINATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S21"},{"id":"a7e8ce59-6e47-48a4-a3dc-42f19d4a4880","order":179,"text":"The Employer has examined the information furnished and designates the leave described in Part I as FMLA leave. The leave will be counted against the Employee's FMLA entitlement.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"approved","type":"add","operator":"="}]},{"id":"fea98687-52de-402e-acb6-7fbf191f8819","order":180,"text":"The Employer is not yet able to determine whether the leave described in Part I is FMLA-qualifying, further information being required as stated in the provision of this packet entitled ADDITIONAL INFORMATION REQUIRED. A designation notice will be issued within five business days after the Employer has received that information.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"pending","type":"add","operator":"="}]},{"id":"f1a33c89-8d73-4748-a228-2bc2791fe3b5","order":181,"text":"The Employer has examined the information furnished and determines that the leave described in Part I is not approved as FMLA leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"denied","type":"add","operator":"="}]},{"id":"c73ad76c-b906-46fb-8d28-caf5ff9e9add","order":182,"text":"The reason for this determination is the following:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"denied","type":"add","operator":"="}]},{"id":"b835b426-9b35-49a8-9673-7afc7e96cc25","order":183,"text":"[Reason the leave is not approved]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"denied","type":"add","operator":"="}]},{"id":"4002dec1-4ba6-4a11-8b83-0e9e045e317c","order":184,"text":"Where leave qualifies under the FMLA, the designation may in appropriate circumstances be made retroactively upon appropriate notice, provided that the retroactive designation does not cause harm or injury to the Employee. The Employer and the Employee may also agree to a retroactive designation, as provided at 29 C.F.R. § 825.301(d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"d2ac39e0-3f0a-4644-a93b-64497381d9b2","order":185,"text":"22. ADDITIONAL INFORMATION REQUIRED","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"pending","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S22"},{"id":"7745c84c-867a-4da8-bf0a-ea89eec518bc","order":186,"text":"Before a determination can be made the Employee must furnish the following:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"pending","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"55859169-cb5e-4a8d-92c7-50bf61d8cc2d","order":187,"text":"[Information still required]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"pending","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"14c9b631-87e3-4104-b93e-d6ca721f9c2f","order":188,"text":"The Employee must furnish that information within seven calendar days of receiving this notice, unless it is not practicable to do so in the particular circumstances despite the Employee's diligent good faith efforts, as provided at 29 C.F.R. § 825.305(c).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"pending","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"2070bd1e-df7e-41d7-b961-7f1cdeb10880","order":189,"text":"If the information is not furnished within the time allowed, FMLA protection for the leave may be denied.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"pending","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"c9e4a51e-9872-4b3d-9822-476a0814f763","order":190,"text":"23. LEAVE COUNTED AGAINST THE FMLA ENTITLEMENT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"approved","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S23"},{"id":"7a860613-dba4-4b77-b3c6-b2e00367a93c","order":191,"text":"The amount of leave counted against the Employee's FMLA entitlement is the following: [Amount counted against the entitlement].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"approved","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"5c1f11ae-7edb-407d-adc3-76ba38514dfb","order":192,"text":"Where the amount of leave needed is not known at the date of this notice, the Employer will notify the Employee, upon request, of the amount counted against the entitlement, no more often than once in a 30-day period and only where leave was taken in that period, as provided at 29 C.F.R. § 825.300(d)(6).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"approved","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"0a8a19bc-23b4-4a86-931f-403f0a1758b7","order":193,"text":"That information may be given orally or in writing. Where it is given orally, the Employer will confirm it in writing no later than the following payday, unless that payday falls less than one week after the oral notice, in which case the confirmation will be given no later than the subsequent payday.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4215610c-104a-47ce-80bb-9c5b55414248","value":"approved","type":"add","operator":"="},{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"cce7b7cd-cc1b-48e0-9993-b92bcb325dda","order":194,"text":"24. EFFECT OF THIS DESIGNATION NOTICE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"20","sectionNum":"S24"},{"id":"0f52ec91-fcb2-4aac-9c29-c75d387bb4ab","order":195,"text":"Leave that qualifies under the FMLA and that is designated as FMLA leave is counted against the Employee's entitlement. Neither the Employer nor the Employee may decline the FMLA designation of leave that qualifies as FMLA leave, and the Employee may not waive prospective rights under the FMLA, as provided at 29 C.F.R. § 825.220(d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"55823104-4e66-417a-bfed-01dc85da983f","order":196,"text":"Where the circumstances of the leave change, the Employer and the Employee will each notify the other within two business days where practicable, and the Employer may issue a revised designation notice.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"a8352cae-4c14-4007-bd48-fdce663a97e7","order":197,"text":"The requirement stated in the provision of this packet entitled SUBSTITUTION OF ACCRUED PAID LEAVE, and the requirement stated in the provision entitled FITNESS-FOR-DUTY CERTIFICATION, form part of this designation notice, as required by 29 C.F.R. § 825.300(d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the birth of the Employee's child and to care for the newborn child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the placement of a child with the Employee for adoption or foster care and to care for the newly placed child","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for the Employee's spouse, son, daughter or parent who has a serious health condition","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"a qualifying exigency arising out of the covered active duty status, or the notification of an impending call or order to covered active duty status, of a military member","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"to care for a covered servicemember with a serious injury or illness","type":"remove","operator":"="}]},{"id":"a369d82c-d1b2-433a-8859-49b035692b3f","order":198,"text":"The requirement stated in the provision of this packet entitled SUBSTITUTION OF ACCRUED PAID LEAVE forms part of this designation notice, as required by 29 C.F.R. § 825.300(d).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="},{"field":"d2731454-f3fc-41a5-a111-50a3b110b391","value":"the Employee's own serious health condition","type":"remove","operator":"="}]},{"id":"9b79e148-a108-4a04-8f35-8d414589d492","order":199,"text":"This notice does not limit any right of the Employee to take leave under any other policy of the Employer or under any applicable law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}]},{"id":"6d1a4d00-aa8a-461f-8ba5-7d8b7de35f99","order":200,"text":"PART V — GENERAL PROVISIONS","fontSize":"16","textAlign":"center","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"displayConditions":[{"field":"d6baef0c-6c1b-453a-9538-e3c501e2bc14","value":"not eligible","type":"remove","operator":"="}],"marginTop":"25"},{"id":"9dd7a545-cc55-4593-9d72-4d30fdf3ab89","order":201,"text":"25. CONFIDENTIALITY OF MEDICAL INFORMATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S25"},{"id":"9960afd8-8a1e-491a-8c37-86bbccdc17cf","order":202,"text":"Records and documents relating to certifications, recertifications and medical histories created for the purposes of the FMLA are maintained as confidential medical records in files separate from the usual personnel files, as provided at 29 C.F.R. § 825.500(g).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"77a60b01-9375-452b-bc05-ea90df48b801","order":203,"text":"Access to those records is confined to the persons identified in that provision, namely supervisors and managers who need to be informed of necessary restrictions and accommodations, first aid and safety personnel where relevant, and government officials investigating compliance with the FMLA.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"192b5ae1-36e9-4cbb-920e-15ecdc7fa3c9","order":204,"text":"Where the Americans with Disabilities Act applies, those records are also maintained in accordance with its confidentiality requirements.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cd78ee79-d189-471c-a2df-f22432968897","order":205,"text":"26. PROHIBITION ON INTERFERENCE AND RETALIATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S26"},{"id":"7bc5a178-6f13-459f-aebf-01753406c8fe","order":206,"text":"It is unlawful for an employer to interfere with, restrain or deny the exercise of any right provided by the FMLA, or to discharge or discriminate against any person for opposing a practice made unlawful by the FMLA or for involvement in any proceeding under it, as provided at 29 U.S.C. § 2615 and 29 C.F.R. § 825.220.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"4991048d-05c1-4b1c-ad0f-de3f9202974e","order":207,"text":"The Employee's exercise of rights under the FMLA will not be used as a negative factor in any employment action, including hiring, promotion, discipline, or the application of an attendance policy.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"0998e2b0-8b2c-4664-96c8-48297e8299b1","order":208,"text":"An employee may file a complaint with the Wage and Hour Division of the United States Department of Labor or may bring a private action in a court of competent jurisdiction. The FMLA does not affect any federal or State law prohibiting discrimination, nor does it supersede any State or local law or any collective bargaining agreement that provides greater family or medical leave rights.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"2afac9ba-12fe-430e-a118-8cc8e58fed8a","order":209,"text":"27. RELATIONSHIP WITH OTHER LAWS, POLICIES AND BENEFITS","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S27"},{"id":"f9c9f21a-374b-42c7-9ac4-40d718f5ae5b","order":210,"text":"Nothing in this packet reduces any right of the Employee under the laws of the State of [State], under any local ordinance, or under any collective bargaining agreement or employee benefit plan providing greater family or medical leave rights, as provided at 29 C.F.R. § 825.701.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"13177cf4-deeb-4be1-9bbb-f86758738b4a","order":211,"text":"Where a leave qualifies both under the FMLA and under a State family or medical leave law, the leaves run concurrently to the extent that the State law permits, and the provision more beneficial to the Employee governs each right.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5c79a82a-cc55-485e-9fd1-bf6e11650eab","order":212,"text":"Where the Employee's condition is also a disability within the meaning of the Americans with Disabilities Act, the Employer will consider its obligations under that Act, including the obligation to provide a reasonable accommodation, independently of its obligations under the FMLA, as provided at 29 C.F.R. § 825.702.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"4c404d18-5dd7-43fb-8cf1-1e29d6265ffb","order":213,"text":"Where the absence also arises from a work-related injury covered by a workers' compensation program, the leave may run concurrently with FMLA leave, provided that the Employer designates it as FMLA leave and notifies the Employee of the designation.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"dfd34c19-1353-4eca-8c57-b6c96aff8039","order":214,"text":"Nothing in this packet creates a contract of employment or alters the at-will character of the employment relationship where that character applies.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"713beab3-d6cd-4a4f-aa4c-afb9ea8ccc15","order":215,"text":"28. RECORDKEEPING AND GENERAL NOTICE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S28"},{"id":"8551e205-bf42-489a-a04b-ac09cf07bf8b","order":216,"text":"The Employer maintains the records required by 29 C.F.R. § 825.500 for a period of not less than three years and makes them available to the Wage and Hour Division for inspection upon request.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ea01b103-7744-4a37-aaa8-f5424d47a638","order":217,"text":"The Employer posts and keeps posted, in a conspicuous place at every worksite, the general notice explaining the provisions of the FMLA, and includes that general notice in any employee handbook or other written guidance concerning employee benefits or leave rights, as provided at 29 C.F.R. § 825.300(a).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"209a7ee4-608e-4412-b5f6-3360e8c74138","order":218,"text":"29. QUESTIONS AND CONTACT INFORMATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S29"},{"id":"33aa5e2c-be4f-4bbd-8e4b-65780619830d","order":219,"text":"Questions concerning this packet, the leave described in it, or the rights and obligations of the Employee under the FMLA should be addressed to [Name and title of the FMLA contact], who may be reached by telephone at [Telephone number] or by electronic mail at [Email address].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"430e2b0d-ca39-44b2-889c-184f284afc0a","order":220,"text":"Information concerning the FMLA is also available from the Wage and Hour Division of the United States Department of Labor.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"6214e097-4342-4363-9f53-2a63a31f059e","order":221,"text":"30. DELIVERY, ACKNOWLEDGMENT AND SIGNATURES","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S30"},{"id":"b9e903fe-a33c-44fd-bcc9-3a3da7024999","order":222,"text":"This packet is issued by [Employer legal name] on [Date] and is delivered to the Employee by personal delivery.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8d2f135b-11dc-4944-bd41-37bdf1114aae","order":223,"text":"Where delivery is made electronically, it is made in a manner that otherwise satisfies the notice requirements of 29 C.F.R. § 825.300.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b00759f9-2d23-419f-a921-f6b392ca9c77","order":224,"text":"Any document delivered with this packet, including any certification form and any list of the essential functions of the Employee's position, forms part of it.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7ed0899a-8a06-4a3a-94dd-13deb654e83c","order":225,"text":"For the Employer:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"marginTop":"15"},{"id":"e58098cf-a782-4383-809a-8d2b52608022","order":226,"text":"Name and title: [Name and title of the representative]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"289b000a-5d7e-48bd-8f6e-01d0669c7648","order":227,"text":"Signature: ______________________________ Date: ____________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"18","cflou":false,"active":true},{"id":"a94d7d41-baec-4097-9576-31c22039c7c1","order":228,"text":"Acknowledgment by the Employee:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"e46bb9f1-f0df-483d-a3dc-e74cedd79cb5","order":229,"text":"The Employee acknowledges having received a copy of this packet. This acknowledgment records receipt only and does not signify agreement with any determination made by the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e46ec018-c68f-455c-b01d-0ed0618aaf39","order":230,"text":"Signature of the Employee: ______________________________ Date: ____________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true}]