York City (Attachment A)

(Attachment A)aNew York City Transit

New York City Transit AuthorityStaten Island Rapid Transit Operating AuthorityManhattan & Bronx Surface Transit Operating Authority

REQUEST AND NOTIFICATION FOR FAMILY AND MEDICAL LEAVE

DEPARTMENT: RC NO.lDIVISION: .. DATE: _

NAME: __ ~ __ ~ TITLE: ROO: _

PASS NO:_.~ _ SOCIAL SECURITY NO: ---''-- _

1. REASON FOR REQUESTING FMLA LEAVE:

__ My own serious health condition renders me unable to perform the functions of my position.The birth of a child and in order to care for such a child.

__ The adoption of a child or placement of a child for foster care.__ Serious health condition of your: child, spouse, parent.

2. Requested Absence from the Authority

From: , 20 (A.M./P.M.) To: , 20 (A.M./P.M.) Total No. of days: _

Intermittent Leave

-. -----.;""'- ~ --, .

3. I understand that if the leave requested is for my own serious health condition or that of a family member, Imust provide medical certification within 15 calendar days of completing this form and that my failure to doso will result in denial of my leave until such certification is provided. The medical certification must besubmitted to Occupational Health Services, Attention: Compliance and Support Unit, 180 LivingstonStreet, Room 4023, Brooklyn, New York 11201.

5. If this leave is requested for the birth, adoption or placement of a foster child, I agree to provide theAuthority with the appropriate documentation substantiating such request within 15 calendar days ofcompleting this form.

4. I understand that I may be required to submit additional certification at least once every 30 calendar daysas requested by the Authority and that failure to comply with this request within 15 days may result in theAuthority denying continuation of my leave.

6. I understand that, unless I am notified otherwise, this leave will be counted against my annual Family and.' Medical Leave entitlement.

7. I understand that when taking FMLA leave, the Authority will require that I use all applicable paid leave.Such paid leave will be counted against my annual Family and Medical leave entitlement of 12 weeks.

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8. If I currently make contributions for my health benefits, I understand that the Authority will continue to makethese contributions on my behalf and deduct such payments from my wages upon my return from FMLAleave. I understand that if I fail to return to work after my leave, I may be liable for payment of health'insurance premiums paid by the Authority during my FMLA leave.

9. If my leave request is for my own serious illness, I understand that I will be required to provide the Authoritywith a certification from my health care provider that I am physically able to return to work.

10. I understand that when I return from FMLA leave, the Authority will place me in the same position or anequivalent position to the one in which I am presently employed.

11. I understand that a fraudulent FMLA request will subject me to immediate dismissal'.

12. I understand that while I am on FMLA leave I may not apply for or receive Unemployment InsuranceBenefits.

13. I acknowledge that I have received a copy of this form for my records.

_____________ Acknowledged: ~ Pass No: _Employee's Signature Supervisor Date

(If in an emergency situation, information received by:)

Name: Title: Date: _

Request Acknowledged/Approved/Denied (circle one)

Deputy Medical Director Date

DateDepartment Head

[FMLA FORM.doc)

"

Certification of Physician or Practitioner(Family and Medical Leave Act of 1993)

Instructions: To be completed by Practitioner or Physician ~ PLEASE PRINT CLEARY1. Employee '1Name 2. Patient's Name (if other than employee)

I3. The attached sheet describes what is meant by a "serious health condition" under the Family

and Medical Leave Act. Does the patient's condition I qualify under any of the categoriesdescribed? If so, please check the applicable category.

(1) 0

DNone of the above

(2) 0 (3) 0 (4) 0 (5) 0 (6) 0

4. Please state the diagnosis anddescribe the medical facts which support your certification, including a brief statement as tohow the medical facts meet the criteria of one of these categories.

5. Date condijion commenced ~ -'-- _a. Probable duration of condition (and also the probable duration of the patients' present

incapa,ity2 if different)

b. Will it be necessary for the employee to take work only intermittently or to work on aless than full schedule as a result of the condition (including for treatment described inItem 6 below)? If yes, give the probable duration.'

G. If the condition is a chronic condition+condition 4) or pregnancy, state whether the,· ...-.patient is presently incapacitated and the likely duration and frequency of episodes of. ~mcapactty·

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

b. If the patient will be absent from work or other daily activities because of treatment on anintermittent or part-time basis, also provide an estimate of the probable number andinterval between such treatments, actual or estimated dates of treatment if known, andperiod required for recovery if any. _

c. If any of these treatments will be provided by another provider of health services (e.g.,I

physical therapist), please state the nature of the treatments.I

1 Here and elsewhere on this form, the information sought relates only to the condition for which theemployee is taking FMLA leave.2 "Incapacity" for purposes ofFMLA, 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.

'-

ContinuationEmployee'sName Patient's Name (if other than employee)

d. 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 therapyrequiring special equipment).

7. a. If medical eave is required for the employee's absence from work because of theemployee's own condition (including absences due to~egnanSt.. or a chronic condition),is the employee unable to perform work of any kind? U Yes UNoWhat are the medical conditions that interfere with the employee performing theirassigned duties:

b. If able to perform some work within their title please list the functions the employee isable to perform.

r-_- •.•. .., • 1r - ••-, • ,•• ~~.

c. If neither a: nor b. applies, is it necessary for the employee to be absent from work fortreatment? 0 Yes 0 No

8. a. Ifleave is required to care for a family member of the employee with a serious healthcondition, does the patient require assistance for basic medical or personal needs orsafety, or for transportation? 0 Yes 0 No·

b. Ifno, would the employee's presence to provide psychol~cal comfort be beneficial tothe patient or assist in the patient's recovery? 0 Yes UNo

c. If the patient will need care only intermittently or on a part-time basis, please describe thekind of care and indicate the probable duration of this need for care by the familymember (i.e., the employee).

ContinuationEmployee's Name

IPatient's Name (if other than employee)

I have examine~ and hereby certify that theabove information is correct.

(Name)

(please print Ylur first and last name)

(Signature of Health Care Provider & Date)I

(Type of Practice)

(Address} (Telephone number)

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.Include a schedule of date(s) and time(s) you will require leave ifleave is to be takenintermittently or if it will be necessary for you to work less than a full schedule.

(Employee's signature & Pass #)I

(Date)

VOLUNTARY CONSENT

I , give permission for a health care provider representing theNew York City Transit Authority, to contact the health care provider that signed my FamilyMedical Leave Act Medical Certification form, for the purpose of clarifying and/or validatingauthenticity of the medical certification. Any such inquiry pursuant to this authorization may notseek additional information regarding my health condition or that of a family member.

(Employee's signature & Pass #) (Date)

A "Serious H. alth Condition" means an illness, injury impairment, or physical ormedical condi ion that involves one of the following:

1. Hospit I CareInpatient care i.e., an overnight stay) in a hospital, hospice or residential medical carefacility, including any period of incapacity! or subsequent treatment in connection with orconsequent to uch inpatient care.

2. Absen e Plus Treatment(a) A period of incapacity of more than three consecutive calendar days

(including any subsequent treatment or period of incapacity relating to thesame condition), that also involves:

(1) Treatment' two or more times by a health care provider, by a nurseor physician's assistant under direct supervision of a health careprovider, or by a provider of health care services (e.g., physicaltherapist) under orders of, or on referral by, a health care provider;or

(2) Treatment by a health care provider on at least one occasion whichresults in a regimen of continuing treatment.' under the supervisionof the health care provider.

3. Pregn ncyAny period of ncapacity due to pregnancy, or for prenatal care.

4. Chron c Conditions Requiring TreatmentsA chronic con ition which:

(1) equires periodic visits for treatment by a health care provider, or by aurse or physician's assistant under direct supervision of a health carerovider;

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

(3) ay cause episodic rather than a continuing period of incapacity (e.g.,sthma, diabetes, epilepsy, etc.).

1 "Incapacity", fo, purposes of FMLA, is defined to mean inability to work, attend school or perform otherregular daily acti ities due to the serious health condition, treatment therefor, or recovery therefrom.

2 Treatment inclu es examinations to determine if a serious health condition exists and evaluations of thecondition. Treat ent does not include routine physical examinations, eye examinations or dentalexaminations.

3 A regimen of co tinuing treatment includes, for example, a course of prescription medication (e.g., anantibiotic) or ther py requiring special equipment to resolve or alleviate the health condition. A regimen oftreatment does no include the taking of over-the-counter medications such as aspirin, antihistamines, orsalves; or bed-res, drinking fluids, exercise, and other similar activities that can be initiated without a visitto a health care pr vider.

5. Perm neat/Long-term Conditions Requiring SupervisionA period of in apacity' which is permanent or long-term due to a condition for whichtreatment maylnot be effective. The employee or family member must be under thecontinuing SURrerViSionof, but need not be receiving active treatment by, a health careprovider. Exa pIes include Alzheimer's, a severe stroke, or the terminal stages of adisease.

6. MultiBle Treatments (Non-Chronic Conditions)Any period oflabsence to receive multiple treatments (including any period of recoverytherefrom) by a health care provider or by a provider of health care services under ordersof, or on referrri I by, a health care provider, either for restorative surgery after an accidentor other injury or for a condition that would likely result in a period of incapacity' ofmore than thre

lconsecutive calendar days in the absence of medical intervention or

treatment, suc~ as cancer (chemotherapy, radiation, etc.) severe arthritis (physicaltherapy), kidnlY disease (dialysis).

NOTE: Ordinarily, unless complications arise, the common cold, the flu, earaches, upset stfmach, minor ulcers, headaches other than migraines, routine dental ororthodontia pr I blems, periodontal disease, etc., are examples of conditions that DO NOTmeet the defini ion of a serious health condition and DO NOT qualify for Flvll.A leave.

Your Rightsunder the

Family and Medical Leave Act of 1993., ...•:........•. ,.:. •....... ' .. , ,. -" .

FMLA requires covered employers to provide up to 12weeks of unpaid, job-protected leave to "eligible"employees for certain family and medical reasons.Employees are eligible if t ey have worked for theiremployer for at least one ear, and for 1,250 hours over

Unpaid leave must be gra ted for any of the followingreasons: .• to care for the employee's child after birth, or placement

for adoption or foster care;• to care for the employee' spouse, son or daughter, or

parent who has a seriou health condition; or .• for a serious health condition that makes the employee

unable to perform the employee's job.At the employee's or employer's option, certain kinds ofpaid leave may be substit Ited for unpaid leave.

The employee may be reqJ1ired to provide advance leavenotice and medical certifidation. Taking of leave may be ..denied if requirements are not met.• The employee ordinaril must provide 30 days advance

notice when the leave is "foreseeable."• An employer may requir medical certification to

support a request for lea e because of a serious healthcondition, and may requi e second or third opinions (atthe employer's expense) nd a fitness for duty report toreturn to work.

• For the duration ofFML leave, the employer mustmaintain the employee's ealth coverage under any"group health plan."

the previous 12 months, and if there are at least 50employees within 75 miles. The FMLA permitsemployees to take leave on an intermittent basis or to ..work a reduced schedule under certain circumstances.

• Upon return from FMLA leave, most employees mustbe restored to their original or equivalent positions withequivalent pay, benefits, and other employment terms.

• The use of FMLA leave cannot result in the loss of anyemployment benefit that accrued prior to the start of anemployee's leave.

FMLA makes it unlawful for any employer to:• interfere with, restrain, or deny the exercise of anyright provided under FMLA:

• discharge or discriminate against any person foropposing any practice made unlawful by FMLA or forinvolvement in any proceeding under or relatingto FMLA.

• The U.S. Department of Labor is authorized toinvestigate and resolve complaints of violations.

• An eligible employee may bring a civil action againstan employer for violations.

FMLA does not affect any Federal or State lawprohibiting discrimination, or supersede any State orlocal law or collective bargaining agreement whichprovides greater family or medical leave rights.

If you have access to the Internet visit our FMLAwebsite: http://~,,'V.dol.gov/esa/whd./fmta.Tolocate your nearest Wage-Hour Office, telephone ourWage-Hour toll-free information and help line at 1-866-4USWAGE (1-866-487-9243): a customer servicerepresentative is available to assist you with referralinformation from 8am to 5pm in your time zone; or logonto our Home Page at http://www.wagehour.dotgo.v.

*U.S. GOVERNMENT PRINTING OFFICE 2001-476-344/49051