GCCC-F2

EMPLOYEE NOTICE OF ELIGIBILITY OF FAMILY OR MEDICAL LEAVE

Date:___________________________________

TO:_______________________________________________________________

FROM:_____________________________________________________________, Superintendent


On _____________________________, you notified us of your need to take family/medical leave beginning on_________________ due to:


☐ The birth of a child, or the placement of a child with you for adoption or foster care

☐ Your own serious health conditions

☐ A serious health condition affecting your ☐spouse, ☐ child, ☐ parent, for which you are needed to provide care

☐ A qualifying exigency because a family member is on or has been called to Active duty in the Armed Forces

☐ Leave to care for a family member who is a member of the Armed Forces or covered veteran and who is undergoing medical treatment, recuperation, or therapy for a serious injury or illness


This Notice is to inform you that:

☐ You are eligible for leave under the FMLA

☐ You are not eligible for leave under the FMLA for the following reason(s):

_______You have not met the FMLA’s 12 month length of service requirement

_______You have not met the FMLA’s hours of service requirement

_______You have exhausted your FMLA entitlement in this 12-month period


RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE

As explained above, you meet the eligibility requirements for taking FMLA leave and still have FMLA leave available in the applicable 12-month period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must return the following information to us by __________________________. If sufficient information is not provided in a timely manner, your leave may be denied.

_____Sufficient certification to support your request for FMLA leave. A certification form is enclosed.

_____Sufficient documentation to establish the required relationship between you and your family member.

_____Other information needed:___________________________________________________________

_____No additional information requested.


If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave:

  • If you will be taking an UNPAID FMLA leave and you want to continue healthcare benefits contact the Business Office to make arrangements to continue payment of your share of the premium. You have a minimum 30-day grace period in which to make premium payments.
  • If your leave is PAID leave, as long as you remain on payroll your benefit deductions will continue as usual.
  • While on leave you will be required to furnish us with periodic reports of your status and intent to return to work.
  • You will be required to present a fitness for duty certificate prior to returning to work.


If your leave does qualify as FMLA leave the following applies:

  • Under the federal Family Medical Leave Act you have a right for up to 12 weeks of unpaid leave in a 12–month period.
  • Under the RI Parental and Family Medical Leave Act you have the right for up to 13 consecutive work weeks of parental or family leave in any two calendar years.
  • Under the federal FMLA you have a right for up to 26 weeks of unpaid leave in a single 12 month period to care for a covered Service Member with a serious injury or illness.
  • Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work.
  • You must be reinstated to the same or an equivalent job with the same pay, benefits and terms and conditions of employment on your return from FMLA-protected leave
  • You have the right to use accrued sick and/or vacation time run concurrently with your unpaid FMLA leave entitlement


Once we obtain the requested information from you we will inform you whether your leave will be designated as FMLA leave and count towards your federal FMLA and/or RI leave entitlements.


Certification for EmployeeWH-380-E.pdf


Certification for Family MemberWH-380-F.pdf


Certification for Current Service Member Military LeaveWH-385.pdf


Certification for Qualifying Exigency Military FamilyWH-384.pdf