STATE OF VERMONT
Employer Response to Request for Family or Medical Leave
This form is to be completed when an employee has requested, either in writing or verbally, leave (sick, annual, personal, compensatory) that is qualifying as Family or Parental Leave. Family Leave is for an EMPLOYEE'S OWN "serious illness" or to care for a FAMILY MEMBER with a "serious illness." Parental Leave is for the birth of your child, your medical condition due to your pregnancy, or the placement of a child with you for adoption or foster care. Please consult the Collective Bargaining Agreement for definitions of terms used herein. No combination of paid and/or unpaid leaves may extend the leave beyond 12 weeks or 16 weeks for Parental leave beginning with the first day either type of leave is used during a 12-month period.
Employee Name:___________________________________________________ Date: ________________
Department Name:____________________________________ Supervisor's Name:___________________
How did the need for leave arise? Check one.
[ ] Verbal request [ ] Written request [ ] Management designation
On _____________ (date), you requested a Family or Parental Leave, or the State otherwise became aware of your need to be absent from work, because of:[ ] the birth of your child, your medical condition due to your pregnancy, or the placement of a child with you for adoption or foster care;
[ ] a serious health condition that makes you unable to perform your job;
[ ] a serious health condition affecting your immediate family (as defined in the employee contract), for which you are needed to provide or arrange for health care;
[ ] a circumstance for which you are requesting short-term parental or family leave.
DECISION:
The following determination has been made regarding your eligibility for Parental or Family Leave.You are [ ] eligible [ ] not eligible
The State hereby approves your Parental or Family Leave, starting on ________________ (date), and continuing until ________________ (date). Your Parental or Family Leave will involve:NOTE: Management has the discretion to deny employee00 request for intermittent or reduced leave schedule as it pertains to Parental Leave. An employee who qualifies for Family leave and the leave is medically necessary may be granted intermittent or reduced leave schedule. See Article 35, Section 6.
[ ] a continuous absence from work
[ ] an intermittent absence (from work, in accordance with the schedule listed on the Employee Request for FMLA form (PERFMLA 1) section 6
[ ] a reduced work schedule, in accordance with the schedule listed on the Employee Request for FMLA form (PERFMLA 1) section 6
ADDITIONAL INFORMATION:
If you are eligible under the State/VSEA Collective Bargaining Agreement [00mployee contract00, you have the right: to take up to 16 weeks of unpaid Parental Leave in a 12-month period or12 weeks of unpaid Family Leave in a 12-month period
to use, at your option, up to six weeks of any accrued paid leave, including sick, annual, and personal leave and compensatory time, during such a leave, but that no combination of paid and unpaid leaves may extend the leave beyond 12 weeks or 16 weeks for Parental leave to request other types of paid or unpaid leave in accordance with the order of leave specified in the Collective Bargaining Agreement (s). Any request for an extension beyond the required Parental or Family Leave will be in accordance with the Collective Bargaining Agreement(s). This absence from work [ ] will [ ] will not be counted against your parental and/or family leave entitlement under the Family Medical Leave Act, 29 U.S.C. 2601, et. seq., and the Vermont Parental and Family Leave Act, 21 V.S.A. 470 et. seq. Please explain the reason(s) that this absence does not count against the employee00 entitlement. You [ ] will [ ] will not be required to furnish medical certification of a serious health condition. If required, you must furnish certification by _____________ (date must be at least 15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted. You [ ] will [ ] will not be required to furnish re-certification relating to that condition, at the following intervals. Your health benefits will be maintained during Parental or Family leave under the same conditions as if you continued to work, and you will be responsible for continuing to pay your portion of the premiums for your health insurance during the leave. Should you go into an unpaid status during Parental or Family Leave, you must pay your portion of premium payments by the Wednesday prior to each payday in order to maintain coverage. The State reserves the right to recover any premium payments you fail to make during the leave. While on leave, you [ ] will [ ] will not be required to furnish the State with periodic reports every __________________________ (indicate interval of periodic reports, as appropriate for the particular leave situation) of your status and intent to return to work . If the circumstances of your leave change and you are able to return to work before the date indicated in this form, you should inform your employer of your situation and request permission to return to work.Nothing in this document is intended to expand or diminish your rights under the employee contract. In the event of conflict between the terms hereof and the employee contract or statutes, your rights will be determined by reference to those authorities.
Employer Signature:______________________________________________Date:____________________
ALL DOCUMENTATION RELATED TO FAMILY LEAVE MUST BE FORWARDED TO YOUR DEPARTMENT'S HUMAN RESOURCES SECTION FOR RECORD KEEPING. WRITTEN INFORMATION RELATED TO FAMILY LEAVE IS CONSIDERED CONFIDENTIAL AND IS KEPT IN A MEDICAL FILE IN YOUR DEPARTMENT'S PERSONNEL UNIT.
EMPLOYER RESPONSE TO REQUEST FOR FAMILY AND MEDICAL LEAVE
PERFMLA 2
