Response to Employee Request for Family or Medical Leave Template

This response to employee request for family or medical leave template has 2 pages and is a MS Word file type listed under our human resources documents.

Sample of our response to employee request for family or medical leave template:

RESPONSE TO REQUEST FOR FAMILY OR MEDICAL LEAVE OF ABSENCE Employee Name: Date: Department: Title: On [Date] you notified us of your need to take family/medical leave due to: The birth of a child or the placement of a child for adoption or foster care; or A serious health condition that you need care for; or A serious health condition affecting your spouse/child/parent, for which you are needed to provide care. You requested leave beginning [Date] and ending on or about [Date]. This is to inform you that (check appropriate boxes): 1. You are eligible not eligible for leave under the FMLA (Family/Medical Leave of Absence). 2. The request leave will will not be counted against your annual FMLA leave entitlement. 3. 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 within 15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted. 4. You may elect to substitute accrued paid leave for unpaid FMLA leave. We will will not require that you substitute accrued paid leave for unpaid FMLA leave. If paid leave will be used, the following conditions will apply: If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of your FMLA leave. Arrangements for payment have been discussed with you and it is agreed that you will make the premium payments as follows: You have a [Number] day grace period in which to make payment. If payment has not been made within that period, your group health insurance may be canceled, or, at our option, we may pay your share of the premiums during FMLA leave, and recover these payments from you upon your return to work. We will will not pay your share of the premiums for your health insurance while you are on leave