Family & Medical Leave
 Provisional Notification
for Postdoctoral Trainees

 

 

Letter must be copied on department/division letterhead)   

TO:  _______________________________________ DATE: __________________
(Name)

_______________________________________    
(Home Address)

_______________________________________


FROM: _____________________________________ PHONE: _________________
(Name of Training Program Director)


On __________________, we became aware of your need to take family/medical leave

          (Date)          

due to:

 

the birth of your child, or the placement of a child with you for adoption or foster care
(Within twelve (12) months following birth, adoption, or placement for foster care); or

NOTE: Absences for prenatal visits may qualify toward Family/Medical Leave

NOTE: For the placement of a child, you must provide written documentation of the adoption or
foster care (i.e., court order, etc.). This documentation must be submitted to the Office of Occupational Health, 98 N. Broadway, Suite 421, Baltimore, Maryland  21231, Attention:  Frances Humphrey

 

a serious health condition that makes you unable to perform the essential functions of your job; or

 

a serious health condition affecting your spouse, same sex domestic partner, child or parent for which you are needed to provide care.

Name: __________________________  Date of Birth: ____________ 

Relationship: ____________________

You notified us that you need this leave beginning on ________________  and that you expect leave to continue until on or about _________________.

You have a right under the Family and Medical Leave Act (”FMLA”) for up to twelve (12) weeks of unpaid leave in a twelve (12) month period (July 1st through June 30) for the reasons stated above, if eligible. The university requires that you substitute accrued paid leave for unpaid FMLA leave.  Your health benefits will be maintained during any period of unpaid leave and you will be reinstated to the same position with the same pay, benefits, and terms and conditions of appointment on your return from leave. These points are discussed in more detail below.
 
Based on the information available, it appears that the leave provisionally qualifies as Family and Medical Leave effective __________________ (date).  Should you have any questions concerning your obligations or rights under the university's Family and Medical Leave Policy, please contact (Training Program Director or Administrator.) If you fail to meet the obligations, the taking of Family and Medical Leave may be delayed or denied.


 CERTIFICATION:
  
You will be required to furnish medical certification of a serious health condition or the serious health condition of a family member.  Attached, as Attachment A, is a “Certification of Health Care Provider” to be completed by you or your family member's health care provider. This initial Certification must be submitted to the Office of Occupational Health Services, 98 N. Broadway, Suite 421 Baltimore, Maryland  21231 within 15 days of this request, or by ______________.  Upon receipt of the requested documentation, a final determination will be made.  If the documentation you submit does not support Family and Medical Leave, or if you fail to provide the requested documentation, the leave will not be approved as Family and Medical Leave and university policies and procedures covering absences will be applied.

The university may require subsequent Certifications during your leave at 30 day intervals or other reasonable times. A new Certification may be requested if the circumstances of your leave change.  If you are taking leave on an intermittent or reduced leave schedule, Certification will be required every 12 months.


LEAVE BALANCES:

As of the date your leave commenced, you had _______ sick days and ________ vacation days remaining for the current year.

If you are taking leave due to your own serious health condition, for prenatal care or birth of a child, leave will be charged first to any sick time you may have, then to vacation, then to leave without pay. In the event leave is for the birth of a child, once released by your physician, leave will be charged to vacation then to leave without pay. Please refer to Parental, Maternity and Adoption Leave Policy for Trainees for information regarding paid leave.

If you are taking leave due to the serious health condition of a family member (spouse, same sex domestic partner, child or parent), leave will be charged to vacation, then to leave without pay.

If you are taking leave due to the adoption of a child, or placement of a child with you for foster care, you will be eligible for six weeks of leave with pay (5 weeks adoption and 1 week parental), then vacation leave, and finally leave without pay. If both parents are employed by the university, only the parent who is the primary caregiver is eligible for the six week paid leave, and both parents together are entitled to a total of 12 weeks of Family and Medical Leave in a 12 month period.

For Trainees whose regular funding source does not provide for paid leave, reference to paid leave, including sick time, vacation leave, parental leave and adoption leave refer to the time allotment only and do not confer any right for paid leave unless provided by another source.


MAINTENANCE OF BENEFITS:

Your health benefits will be maintained under the same condition as if you continued to work.

RETURN TO WORK:

During leave, you may be required to report periodically on your status and intention to return to work. If the circumstances of your leave change and you are able to return to work earlier than the date indicated above, we ask that you notify us at least two work days prior to the date you intend to report for work.

You are expected to notify your Training Program Director at least two weeks prior to the expiration of the leave of your intent to return to work and, in any event, must provide a minimum of two days notice of readiness to return to work. If the reason is due to your own serious health condition you must provide a written release from your Health Care Provider stating that you are fit to return to work. This release must be taken to the Occupational Health Services Office, 98 N. Broadway, Suite 421 Baltimore, Maryland  21231, (410) 955-6211. The Occupational Health Office will give you clearance to return to your job.  If a release to return is not submitted, your return to work may be delayed until the release is provided.

IMPORTANT NOTICE:

Trainees should be aware that the amount of leave taken may affect their ability to meet the requirements of a certifying board, if applicable, and should be discussed with the Training Program Director.  Any leaves in excess of paid vacation will be treated as leave of absence from the Program.

If you engage in other employment during this leave, you may be considered to have violated the terms of the leave and have voluntarily terminated your appointment with the university.

Please keep this letter as part of your records. You will receive an FML Determination confirming approval or denial of your request for leave. Also, please refer to the attachment outlining your rights and obligations under Family and Medical Leave.

If you have any questions about this policy, please contact me or the department administrator, (NAME).

Sincerely,

(Training Program Director)

cc:  Julia McMillan, M.D., Office of Graduate Medical Education or

Levi Watkins, Jr., M.D., Office of Postdoctoral Programs
Frances Humphrey, Occupational Health Services

Attachments: 
A: Certification of Health Care Provider
b: U. S. Department of Labor Program Highlights - The Family and Medical Leave Act of 1993

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved by the Graduate Medical Education Committee

June 13, 2007

 

 

 

 

Certification of Health Care Provider (Family and Medical Leave Act of 1993)

U.S. Department of Labor

Employment Standards Administration Wage and Hour Division

 

(When completed, this form goes to the employee, Not to the Department of Labor.)                             OMB No.: 1215-0181

________________________________________________________________ _ Expires: 09-30-2010

1. Employee’s Name                                                             2. Patient’s Name (If different from employee)

3.    Page 4 describes what is meant by a “serious health condition” under the Family and Medical Leave Act. Does the patient’s condition1 qualify under any of the categories described? If so, please check the applicable category.

(1)________ (2)________ (3)                (4)________ (5)_______ (6)________ , or None of the above________

4.    Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria of one of these categories:

5.    a. State the approximate date the condition commenced, and the probable duration of the condition (and also the probable duration of the patient’s present incapacity2 if different):

b.    Will it be necessary for the employee to take work only intermittently or to work on a less than full schedule as a result of the condition (including for treatment described in Item 6 below)?

If yes, give the probable duration:

c.    If the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incapacitated2 and the likely duration and frequency of episodes of incapacity2:

1 Here and elsewhere on this form, the information sought relates only to the condition for which the employee is taking FMLA leave.

2 “Incapacity,” for purposes of FMLA, is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefor, or recovery therefrom.

Form WH-380 Page 1 of 4                                                                                                                                                                               Revised December 1999

6. a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments.

If the patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number of and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:

b.       If any of these treatments will be provided by another provider of health services (e.g., physical therapist), please state the nature of the treatments:

c.       If a regimen of continuing treatment by the patient is required under your supervision, provide a general description of such regimen (e.g., prescription drugs, physical therapy requiring special equipment):

7. a. If medical leave is required for the employee’s absence from work because of the employee’s own condition (including absences due to pregnancy or a chronic condition), is the employee unable to perform work of any kind?

b.       If able to perform some work, is the employee unable to perform any one or more of the essential functions of the employee’s job (the employee or the employer should supply you with information about the essential job functions)? If yes, please list the essential functions the employee is unable to perform:

c.       If neither a. nor b. applies, is it necessary for the employee to be absent from work for treatment?

 

8. a. If leave is required to care for a family member of the employee with a serious health condition, does the patient require assistance for basic medical or personal needs or safety, or for transportation?

b. If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in the patient’s recovery?

c. If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need:

 

 

 

Signature of Health Care Provider                                                                                                           Type of Practice

Address                                                                                                                                                         Telephone Number

 

 

Date

To be completed by the employee needing family leave to care for a family member:

State the care you will provide and an estimate of the period during which care will be provided, including a schedule if leave is to be taken intermittently or if it will be necessary for you to work less than a full schedule:

Employee Signature                                                                                                                                   Date

A “Serious Health Condition” means an illness, injury impairment, or physical or mental condition that involves one of the following:

1. Hospital Care

Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity2 or subsequent treatment in connection with or consequent to such inpatient care.

2. Absence Plus Treatment

(a) A period of incapacity2 of more than three consecutive calendar days (including any subsequent treatment or period of incapacity2 relating to the same condition), that also involves:

(1)     Treatment3 two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or

(2)     Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment4 under the supervision of the health care provider.

3. Pregnancy

Any period of incapacity due to pregnancy, or for prenatal care.

4. Chronic Conditions Requiring Treatments

A chronic condition which:

(1)       Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under direct supervision of a health care provider;

(2)       Continues over an extended period of time (including recurring episodes of a single underlying condition); and

(3)       May cause episodic rather than a continuing period of incapacity2 (e.g., asthma, diabetes, epilepsy, etc.).

5. Permanent/Long-term Conditions Requiring Supervision

A period of Incapacity2 which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages of a disease.

6. Multiple Treatments (Non-Chronic Conditions)

Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of Incapacity2 of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), and kidney disease (dialysis).

This optional form may be used by employees to satisfy a mandatory requirement to furnish a medical certification (when requested) from a health care provider, including second or third opinions and recertification (29 CFR 825.306).

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

3   Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or dental examinations.

4   A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.

Public Burden Statement

We estimate that it will take an average of 20 minutes to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE; IT GOES TO THE EMPLOYEE.