human resources family medical leave (hr 33)

i o s Angeles County
MetropolitanTransportation Authority
@ Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
POLICY STATEMENT
Federal law (Family Medical Leave Act, or FMLA) and State law (California Family Rights
Act, or CFRA) allow eligible employees to take Family Medical Leave (FML)up to 12
workweeks in a "rolling"12-month period:
for a serious health condition (occupationalor non-occupational)that renders the
employee unable to perform the essential functions of hislher job;
to care for the employee's child, parent, spouse, domestic partner, or child of a
domestic partner, who has a serious health condition; or
to care for the employee's child after birth, or placement of a child with the employee
for adoption or foster care.
FMLA allows employees additional leave entitlement for military reasons. For more
information, see HR Policy 14, Military Leave.
PURPOSE
To provide eligible employees with family medical leave in compliance with federal and state
law.
APPLICATION
This policy applies to all regular and as-needed LACMTA employees. To the extent the
policy conflicts with the collective bargaining agreement, the collective bargaining
agreement will prevail unless the collective bargaining agreement is in conflict with state or
federal law.
Chief of SBU
ADOPTED: CEO
Effective Date:
4122 1 2 ~ 0
Date o f Last Review:
Family Medical Leave (HR33)
a)
Los Angeles County
Metropolitan Transportation Authority
Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
1.0 PROCEDURES
1.1 Eligibility
Employees who have been employed by LACMTA for more than 12 months (even if
there is a break in service), and have performed at least 1,250hours of service during
the preceding 12-monthperiod, are eligible for up to 12 workweeks of FML in a
"rolling" 12-monthperiod.
1.2 Initiating Family Leave
Employees should notifjr their manager or supervisor at least 30 days in
advance if the need for leave is foreseeable. Employees must provide the date
the FML will commence and the estimated duration of the leave. If the leave
is unforeseen, employees should request FML or notifjr their manager or
supervisor as soon as practicable. As soon as practicable means as soon as
both possible and practical taking into consideration all the facts and
circumstances of the case.
Leave may be taken intermittently or on a reduced work schedule when
medically necessary for the employee's or eligible family member's serious
illness. Employees must attempt to schedule intermittent leave so as not to
disrupt LACMTA's operations.
1.3 Certification of Health Care Provider
An employee requesting FML must provide satisfactory documentation to
support the FML. A Certifkation of Health Care Provider (CHCP) for
Employee's Own Serious Health Condition form (Attachment 1)is required
for an employee's own medical absence. A Certification of Health Care
Provider (CHCP)for Family Member's Serious Health Condition form
(Attachment 2) is required for leave to care for an eligible family member.
The CHCP should be submitted to employee's manager or supervisor:
at the time the employee gives notice of the need for leave, or
within five business days after learning of the need to take leave, or
within five business days after the leave commences.
The employee must provide the CHCP within 15 calendar days unless
circumstances make the 15-daymaximum period not practicable.
Family Medical Leave (HR 33)
Los Angeles County
MetropolitanTransportation Authority
@ Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
1.4 Designation of Family Leave
Upon receipt of an Employee Request for Family Medical Leave form
(Attachment 3), the leave request will be approved or disapproved by the
manager or supervisor within 5 business days. The manager/supervisor will
notif) the employee by completing the Notice of EligibilityJDesignationform
(Attachment4).
If the manager or supervisor has sufficient knowledge that an absence may
quallf) as FML, the manager should designate the absence as FML within five
days, and request the employee to complete the FML forms.
If an employee's leave was not initially designated as FML and the leave
qualifies as FML, the employee and manager or supervisor can mutually agree
that the leave be retroactively designated as FML.
If an employee is on leave due to his/her own serious health condition and is
off work or expected to be off work 30 days or more, the time off will be
considered a leave of absence and the employee's absence will be monitored
in accordance with both the Medical Disability Leave Policy HR #44 and the
FML policy.
1.4.1 General Requirements
The manager or supervisor should notify the employee of his/her
rights and obligations under this policy and explain the consequences
of the employee's failure to comply with its requirements.
The manager or supervisor ensures that the employee requesting FML
completes the appropriate sections of the Employee Request for Family
Medical Leave of Absence form (Attachment 3) and submits a
Certification of Health Care Provider form, if applicable. Based on the
information contained in these documents, the supervisor will
determine if the employee qualifies for FML. Human Resources will
help clarifjr the validity or thoroughness of the medical certification. In
addition, an LACMTA contracted physician may contact the employee's
Health Care Provider, with the employee's permission, to clarif)
and/or authenticate the medical certification.
Family Medical Leave (HR33)
Los Angeles County
Metropolitan Transportation Authority
@ Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
In the event an employee who qualifies for FML does not make a
formal request for FML while on medical disability leave, LACMTA
management, i.e., department management, Human Resources staff,
or Return-to-Work(RTW) Coordinators, may designate the leave as
FML.
It is the employee's responsibility to supply documentation to support
his or her need for FML. A certification is incomplete if required
elements are not provided, and it is insufficient if the information is
vague or ambiguous. If the employee cannot substantiate the need for
leave, then the leave cannot be approved.
Human Resources may require the employee to obtain a second medical
opinion at LACMTA's expense if there is reason to doubt the validity of the
certification. If the second opinion differs from the certification initially
provided by the employee, the supervisor or manager may require a third
opinion from a health care provider agreed upon by LACMTA and the
employee, again at LACMTA's expense. This third opinion will be final and
binding. LACMTA will reimburse the employee for reasonable out-of-pocket
expenses incurred in obtaining the second or third opinions regarding the
employee's serious health condition. All requests for second or third opinions
will be reviewed by the Human Resources Department.
The manager or supervisor may request recertification at the following times:
employee's own serious health condition:
1. upon expiration of the period of leave originally requested and
approved;
2. if manager or supervisor receives information that casts doubt on
the employee's stated reason for absence;
3. annually, when leave lasts beyond one year;
employee's eligible family member:
1. requests for extension of original leave request;
2. annually, when leave lasts beyond one year.
Family Medical Leave (HR33)
Los Angeles County
Metropolitan Transportation Authority
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
1.5 Family Bonding
Employees may use their 12 weeks of FML for family bonding after the birth,
adoption or foster care placement of a child. When family bonding leave is
requested, it need not be taken immediately after the baby is born, but must
conclude within one year of the birth, adoption, or foster care placement of the child
with the employee. If both parents are employed by LACMTA, the total amount of
bonding leave for both employees is 12 workweeks during a rolling 12-monthperiod.
1.G Pay During Leave
Employee time spent on FML must be accurately coded and recorded for
purposes of payroll, benefits, and attendance. FML is an unpaid leave, except
as provided below. Employees may be eligible to receive pay while on FML
under the following conditions:
1.6.1 Represented Employees
1. Sick Leave : While on FML, employees may use any accrued sick
leave for their own serious health condition. Refer to the
Attendance Policy, HR 21 for use of sick leave when the absence is
to care for others. ATU represented employees may use up to
100% of their accrued and available sick leave for any approved
FML. Sick leave allowance cannot be used for bonding with the
exception of ATU represented employees.
Vacation : Afier exhausting their sick leave, employees who are on
FML for their own serious health condition have the option of
using their vacation allowance. When the FML is for other than
the employee's own serious health condition, employees are
required to use their available vacation balance for the first two
weeks of FML and may apply for California Paid Family Leave
Insurance (PFLI) (see section 1.6.4). The use of vacation after this
2-week period is at employee's discretion.
1.6.2 Non-Represented Employees
While on FML, employees with accrued TOWP and/or frozen sick
hours will be paid according to the Time Off with Pay (TOWP) Policy,
HR 16. Frozen sick hours cannot be used for bonding. After
exhausting TOWP and frozen sick leave, employees may use any
frozen vacation.
Family Medical Leave (HR 33)
Page 5
Los Angeles County
MetropolitanTransportation Authority
@ Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
1.6.3 State Disability Insurance
An employee is eligible for State Disability Insurance (SDI)benefits
d u r i n c if~the
~ ~
ieave is taken for the er&ployee'sown sekous health
condition. Where applicable, SDI will be integrated with any paid sick
leave for represented employees or TOWP and frozen sick or vacation
hours for non-representedand AFSCME employees according to the
TOWP Policy, HR 16, Section 1.2.
1.6.4 Paid Family Leave Insurance
Employees may be eligible for PFLI benefits offered by the California
Employment Development Department (EDD)for time off work to care for a
seriously ill child, spouse, parent, domestic partner (as defined by the State of
California),or child of a domestic partner, or for the birth, adoption, or foster
care placement of a child. Contact the local EDD ofice for more information.
There is no length of service requirement before an employee is entitled to
receive PFLI benefits.
1.7 Application of Attendance Policies
Absences approved as FML will not be chargeable under the respective
attendance policies or applicable collective bargaining agreements. All FML
taken, whether paid or unpaid, will be counted toward the maxirnum 12month leave of absence allowed under collective bargaining agreements or the
LACMTA Medical Disability Leave Policy, HR 44. Refer to HR Policy 44 Medical Disability Leave, Section 1.7.
1.8 Return to Work from FML
If the absence is for the employee's own medical condition and is 30 days or
longer, the employee must present a release to return to work from hislher
health care provider(s) and complete the return to work process as specified in
HR Policy 44, Medical Disability Leave. If the absence is less than 30 days,
and the employee suffered a serious non-occupationalinjury or illness
requiring hospitalization, or the employee experienced chest pains, loss of
consciousness, dizziness/loss of balance, or suspected heart attack, the
employee must present a release to return to work from hislher health care
provider(s) and complete a fitness-for-dutyexamination as specified in the HR
Policy 3-18, Fitness-for-Duty. Any absence less than 30 days is covered by HR
Policy 21 - Attendance, or the applicable collective bargaining agreement.
Family Medical Leave (HR33)
Page 6
a)
Los Angeles County
Metropolitan Transportation Authority
Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
At the end of FML, the employee will be reinstated to the same position held,
or to an equivalent position with equivalent benefits, pay, and other terms and
conditions of employment, if available. At the end of FML, if the employee is
unable to perform an essential function of his or her position because of a
physical or mental condition, LACMTA will conduct an interactive process in
accordance with the Reasonable Accommodation Policy, HR 25 to determine
whether a reasonable accommodation can be made.
1.9 Exceptions
Exceptions to the FML 12-weekmaximum are:
ifboth spouses or domestic partners are employed by LACMTA and both are
eligible for FML, each spouse or domestic partner is entitled to 12 workweeks
of leave, unless the leave is taken for the birth of the employees' child or to
care for the child after birth, adoption or foster care placement, in which case,
the total amount of leave for both employees is 12 workweeks during a rolling
12-monthperiod.
if the LC233 absence qualifies as a serious health condition, the LC233 will be
applied to the 12-week maximum allowed for FML.
family leave to care for a covered servicemember with a serious injury or
illness.
2.0 DEFINITION OF TERMS
Child - a biological, adopted, or foster child; a stepchild; a legal ward; or a child of a
person standing in locoparentis,who is under 18 years of age or who is an adult
dependent child who is incapable of self-caredue to physical or mental disability.
Domestic Partners - two adults, at least one of which is an LACMTA employee, who
are in a committed relationship and have signed and filed an LACMTA "Affidavit of
Domestic Partnership" or have filed a State of California Certificate of Domestic
Partnership with LACMTA's Pension and Benefits Department, and 1)share a
common residence; 2) neither is married to someone else or is a member of another
domestic partnership; 3) are not related by blood which would prevent them from
being married to each other in a legal California marriage; 4) are both at least 18
years old; and 5) are both capable of consenting to the domestic partnership.
Family Member - an employee's parent, child, spouse or domestic partner or child of
a domestic partner.
Family Medical Leave (HR 33)
Page 7
Los Angeles County
MetropolitanTransportation Authority
@ Metro
~
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
Health Care Provider - a doctor of medicine or osteopathy who is authorized to
practice medicine or surgery by the state in which the doctor practices; or physician
assistants, podiatrists, dentists, clinical psychologists, optometrists, nurse
practitioners, nurse-midwives, clinical social workers, and chiropractors (limited to
treatment consisting of manual manipulation of the spine to correct a subluxation as
verified by X-ray) authorized to practice in the state and performing within the scope
of their practice as defined under state law; and Christian Science practitioners listed
with the First Church of Christ, Scientist in Boston, Massachusetts. LACMTA may
require that second or third opinions be obtained from health care providers other
than Christian Science practitioners.
A Health Care Provider can also be:
any health care provider from whom LACMTA's group health plans benefits
manager will accept certification of the existence of a serious health condition
to substantiate a claim for benefits; or
a health care provider listed above who practices in a country other than the
United States, who is authorized to practice in accordance with the law of that
country, and who is performing within the scope of his or her practice as
defined under such law.
Intermittent Leave - an approved leave taken in separate periods of time due to a
single illness or injury, rather than for one continuous period of time. FML time off
should be recorded on an actual time (minute-by-minute)basis.
Non-Occupational InjuryIIllness - an injury or illness which is not work-related.
Occupational InjurylIllness - an injury or illness which is work-related.
Paid Family Leave Insurance (PFLI) - an extension of the California State Disability
Insurance (SDI) Program that provides compensation for individuals who take time
off work to care for a seriously ill child, spouse, parent, or domestic partner, or for
the birth, adoption, or foster care placement of a child.
Parent - a biological, foster, or adoptive parent; a stepparent, a legal guardian, or
other person who stood in locoparentisto the employee when the employee was a
child. This term does not include parents-in-law.
Reduced Leave Schedule - a leave schedule that reduces an employee's usual
number of hours per workweek, or hours per workday.
Family Medical Leave (HR33)
Los Angeles County
MetropolitanTransportation Authority
@ Metro
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
Rolling 12-MonthPeriod - a period of 12 months measured backward from the date
an employee begins using any FML.
Serious Health Condition - an illness, injury, impairment, or physical or mental
condition (occupationalor non-occupational) that involves:
1. Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical
care facility, including any period of incapacity (i.e. inability to work, attend school, or
perform other regular daily activities due to the serious health condition, treatment
involved or recovery) or subsequent treatment in connection with the inpatient care.
Continuing treatment by a health care provider that includes any one or more of the
following: A period of incapacity of more than three consecutive calendar days, and
any subsequent treatment or period of incapacity relating to the same condition that
also involves: treatment 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 treatment by a health care provider on at least
one occasion which results in a regimen to continuing treatment 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 treatment: A chronic serious health condition is one
which 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; continues
over an extended period of time (including recurring episodes of a single underlying
condition; and may cause episodic, rather than a continuing period of incapacity, e.g.,
asthma, diabetes, or epilepsy).
5. Permanent/Long-term conditions requiring supervision: A period of incapacity
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 not be receiving treatment by, a health care provider. Examples
include Alzheimer's, a severe stroke, or the terminal stages of a disease.)
Family Medical Leave (HR 33)
Los Angeles County
Metropolitan TransportationAuthority
@lktm
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
6. Multiple treatments (non-chronicconditions): Any period of absence to receive
multiple medical treatments (including any period of recovery)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 incapacity of more than three
consecutive calendar days in the absence of medical intervention or treatment, such
as cancer (chemotherapy,radiation, etc.), severe arthritis (physicaltherapy), or kidney
disease (dialysis).
3.0 RESPONSIBILITIES
Employees submit requests for FML in a timely manner and provide documentation upon
request.
Department headsldivision managers review, approve, and designate requests for FML in a
timely manner, and inform employees of LACMTA FML policies.
Human Resources/RTW Coordinators review medical documentation, designate absences
as FML, provide guidance to management and employees, and coordinate secondlthird
medical opinions.
4.0 FLOW CHART
Not Applicable
5.0 REFERENCES
Family and Medical Leave Act of 1993 (29 USC j 2601-2619)
Family and Medical Leave Act of 1993 (Final Rule)
California Family Rights Act of 1993 (California Government Code 8 12945.2)
California Fair Employment and Housing Act
HR 25 Reasonable Accommodation Policy
HR 44 Medical Disability Leave Policy
7. HR 16 TOWP Policy
8. HR 38 Pregnancy Disability Leave Policy
9. HR 21 Attendance Policy
10. HR 31 Employment Status
11. HR 14 Military Leave Policy
1.
2.
3.
4.
5.
6.
Family Medical Leave (HR33)
Los Angeles County
MetropolitanTransportation Authority
HUMAN RESOURCES
FAMILY MEDICAL LEAVE
(HR 33)
6.0 ATTACHMENTS
1.
2.
3.
4.
Certification of Health Care Provider for Employee's Own Serious Health Condition
Cer=cation of Health Care Provider for Family Member's Serious Health Condition
Employee Request for Family Medical Leave
Notice of EligibilityIDesignation
7.0 PROCEDURE HISTORY
03/23/93
Former LACTC and former SCRTD interim procedures Board-adopted.
08/16/96
Revised to conform to revised law.
01/01/05
Revised to comply with new State laws.
05/05/08
Revised.to reflect new Family Medical Leave legislation and clan@parts of
existing policy.
01/14/10
Revised to reflect revisions to the Family Medical Leave Act.
Family Medical Leave (HR33)
EMPLOYEE
Attachment 1
Certification of Health Care Provider fbr
Employee's Own Serious Health Condition
Family and Medical Leave Act (FMLA) and
California Family Rights Act (CFRA)
Metro
INSTRUCTIONS to the EMPLOYEE:
Please complete this section before giving this form to your Health Care Provider. Failure to provide a complete
and sufficient medical certification may result in a denial of your FMLA request. This form should be completed
within 15 calendar days.
Employee Name
Dept/Div
Badge
Date
INSTRUCTIONS to the HEALTH CARE PROVIDER:
Please complete this section, answer all applicable questions in PART A and PART B, and sign and date the last
page. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your
answer should be your best estimate based upon your medical knowledge, experience, and examination ofthe
patient. Be as specific as possible. Terms such as "lifetime," "as needed," "unknown," or "indeterminate" may
not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is
seeking leave without indicatingthe underlying diagnosis without the patient's consent. (Please print.)
Health Care Provider's Name
Type o f practice
Address
City
Telephone: (
)
State
Fax: (
Zip
1
PART A: M EDlCAL FACTS
Does the patient's condition qualify as a "Serious Health Condition" (SHC) under the Family and Medical Leave
Act and as described in the attached definitions? If so, please check the applicable category:
(1) -
(2) -
(3) -
(4) -
(5) -
(6),
or
No SHC-,
(Ifyou checked "No SHC," please go directly to the bottom o f page 3 and sign and date.)
Approximate date condition commenced:
Probable duration ofcondition:
Page 1 o f 3
Certification of Health Care Provider fbr
Employee's Own Serious Health Condition
1. Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
N
oY
e
s
If so, dates of admission:
Date@)you treated the patient for condition:
Will the patient need to have treatment visits two or more times due to the condition?
Was medication, other than over-the-countermedication, prescribed?
No
No
Yes
Yes
Was the patient referred to other health care provider@)for evaluation or treatment (e.g., physical therapist)?
-No -Yes If so, state the nature and duration of such treatments:
2. Is the medical condition pregnancy?-No
Yes If so, expected delivery date:
3. Is the employee unable to perform any of hislher job functions due to the condition?
No Y
e
s
If so, identify the job functions the employee i s unable to perform:
4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such
medical facts may include symptoms or any regimen of continuing treatment such as the use of specialized
equipment):
PART B: AMOUNT OF LEAVE NEEDED
5. Will the employee be incapacitated for a single continuous period oftime due to hislher medical condition,
including any time for treatment and recovery?
No
Yes
If so, estimate the Start and End dates for the period of incapacity:
Start Date:
End Date:
Page 2 of 3
Certification of Health Care Provider fbr
Employee's Own Serious Health Condition
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced
schedule because of the employee's medical condition?
No
Yes
I
If so, are the treatments or the reduced number of hours of work medically necessary?-No
Yes
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required
for each appointment, including any recovery period:
Estimate the part-time or reduced work schedule the employee needs, i f any:
hour@)per day;
days per week from
through
Date
Date
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job
functions?
No Y e s
Is it medically necessary for the employee to be absent from work during the flare-ups?
If so, explain:
No -Yes
Based upon the patient's medical history and your knowledge ofthe medical condition, estimate the frequency of
flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode
every 3 months lasting 1-2 days):
I
Frequency: t i m e s per
week(s) month -month(s)
hours or day(s) per episode
Duration: -
ADDITIONAL INFORMATION:
Date
Signature o f Health Care Provider
Page 3 of 3
MetropolitanTransportation Authorly
0
Met,,
DEFINITIONS FOR SERIOUS HEALTH CONDITION
A "Serious Health Condition" means an illness, injury, impairment, or physical or mental condition that involves
one of the following:
1.
Inpatient Care - an overnight stay in a hospital, hospice, or residential medical care facility, including any
period of incapacity or subsequent treatment in connection with the inpatient care.
2.
Continuing Treatment a period of incapacity2 of more than three consecutive calendar days and any
subsequent treatment or period of incapacity2relating to the same condition that also involves:
-
(1) treatment3two 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 o f
continuing treatment4under the supervision of the health care provider.
3.
-
Pregnancy any period of incapacity due to pregnancy, or for prenatal care.
NOTE: An employee's own incapacity due to pregnancy is covered as a serious health condition under
FMLA, but not under CFRA.
4.
-
Chronic Condition a 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 incapacity,' e.g., asthma, diabetes, or
epilepsy.
-
5.
PermanentILong-term Conditions Requiring Supervision a period of incapacity2which 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.
.
Multiple Treatments for Non-Chronic Conditions any period o f absence to receive multiple treatments
(including any period of recovery) by a health care provider or by a provider o f 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 o f incapacity2o f more than three consecutive
calendar days in the absence o f medical intervention or treatment, such as cancer (chemotherapy,
radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).
-
Here and elsewhere on this form, the information sought relates only to the condition for which the employee is on leave of absence.
"Incapacity," for purposes of FML, is defined to mean inability t o work, attend school or perform other regular daily activities due to serious
health condition, treatment, or recovery.
' Treatment includes examinations to determine if a serious health condition exists and evaluations o f the condition.
Treatment does not
include routine physical examinations, eye examinations, or dental examinations.
A regimen o f continuing treatment includes, for example, a course o f prescription medication (e.g., an antibiotic) or therapy requiring
special equipment to resolve or alleviate the health condition. A regimen o f treatment does not include the taking 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.
FAMILY MEMBER
Attachment 2
Mef r~
Certification of Health Care Provider fbr
Family Member's Serious Health Condition
Family and Medical Leave Act (FM LA) and
California Family Rights Act (CFRA)
INSTRUCTIONSto the EMPLOYEE:
Please complete this section before giving this form to your family member or his/her Health Care Provider.
Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA
request. This form should be completed and returned within 15 calendar days.
Employee Name
Badge
Family Member's Name
Relationship
Ifchild, indicate birth date:
Dept/Div
(month/date/year)
State the care you will provide:
Employee Signature
Date of Request
INSTRUCTIONS to the HEALTH CARE PROVIDER:
Please complete this section, answer all applicable questions in PART A and PART B, and sign and date the last
page. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your
answer should be your best estimate based upon your medical knowledge, experience, and examination of
the patient. Be as specific as possible. Terms such as "lifetime," "as needed," "unknown," or
"indeterminate" may not be sufficient to determine FMLA coverage. Limit your responses to the condition
for which the patient needs care without indicatingthe underlying diagnosis without the patient's
consent. (Please print.)
Health Care Provider's Name
Address
Type of practice
City
1
State
Fax: (
Page 1 of 4
1
Zip
Certification of Health Care Provider br
Family Member's Serious Health Condition
PART A: MEDICAL FACTS
Does the patient's condition qualify as a "Serious Health Condition" (SHC) under the Family and Medical Leave
Act and as described in the attached definitions? If so, please check the applicable category:
(1) -
(2) -
(3) -
(4) -
(5) -
(6),
or
No SHC
(Ifyou checked the "No SHC," please go directly to the bottom o f page 4 and sign and date.)
Approximate date condition commenced:
Probable duration o f condition:
1. Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
-No
Yes If so, dates o f admission:
Date(s) you treated the patient for condition:
Was medication, other than over-the-counter medication, prescribed?
No -Yes
Will the patient need to have treatment visits two or more times due to the condition?
No -Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
-No Y
I
e
s If so, state the nature and duration of such treatments:
2. Is the medical condition pregnancy?N
o
Yes If so, expected delivery date:
3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care
(such medical facts may include symptoms, or any regimen o f continuing treatment such as the use o f
specialized equipment):
Page 2 o f 4
Certification dHealth Care Provider fbr
Family Member's Serious Health Condition
PART B: AMOUNT OF CARE NEEDED
Your patient's need for care by the employee seeking leave may include assistance with basic medical,
hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment
and recovery?
No
Yes
I f so, estimate the Start and End dates for the period of incapacity:
Start Date:
End Date:
During this time, will the patient need care?
No -Yes
Explain the care needed by the patient and why such care is medically necessary:
5. Will the patient require follow-up treatments, including any time for recovery?-No Y
e
s
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time
required for each appointment, including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for
recovery?
No -Yes
Estimate the hours the patient needs care on an intermittent basis, if any:
hour(s) per day;
days per week from
through
Date
Explain the care needed by the patient, and why such care is medically necessary:
Page 3 of 4
Date
Certification of Health Care Provider k r
Family Member's Serious Health Condition
7. Will the condition cause episodic flare-ups periodically preventingthe patient from participating in
normal daily activities?
No Y e s
Based upon the patient's medical history and your knowledge of the medical condition, estimate the
frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6
months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency:
Duration:
I
times per
week(s) -month -month(s)
hours or -day(s) per episode
Does the patient need care during these flare-ups?
No
Yes
Explain the care needed by the patient, and why such care i s medically necessary:
ADDITIONAL INFORMATION:
Signature of Health Care Provider
Date
Page 4 of 4
Attachment 3
Metro
EMPLOYEE REQUEST
FOR FAMILY MEDICAL LEAVE
~amilyand Medical Leave Act (FMLA)
~aliforniaFamily Rights Act (CFRA) -
INSTRUCTIONS to the EMPLOYEE: Complete either Part A, Part B, or Part C depending on reason for
absence.
Employee Name
Badge
Dept/Div
Date
PART A: Absence for Employee's own serious health condition. (See LACMTA Family
Medical Leave Policy HR #33)
This request is for my own serious health condition.
I have included the required Certification o f Health Care Provider.
PART B: Absence to take care o f others. (See LACMTA Family Medical Leave Policy HR #33)
This request is for the birth o f my child, bonding with newborn child, placement of child with me for
adoption or foster care.
I have included the required proof of birth, adoption or foster care placement
This request is to care for an eligible family member who has a serious health condition.
Indicate relationship:
If child, indicate birth date:
(monthldaylyear)
I have included the required Certification of Health Care Provider
I am required to provide the following care:
PART C: Military Family Leave. (See LACMTA Military Leave Policy HR #14)
This request is for a qualifying exigency because my
spouse
son or daughter
parent is on active duty or has been notified o f an impending call or order to active
duty in support of a contingency operation.
This request is for my -spouse -son or daughter -parent -domestic
partner
child o f my domestic partner
my next of kin who is a covered servicemember
with a serious injury or illness.
Page 1 of 1
Attachment 4
NOTICE O F ELIGIBILITY/DESIG NATION
Family and Medical Leave Act (FM LA) and
California Family Rights Act (CFRA)
Mef r~
INSTRUCTIONS to the DEPARTMENT MANACER/SUPERVISOR:
Complete this form and give to the Employee within 5 working days after receiving notice of the need for leave.
TO:
Employee Name
Badge
Dept/Div
FROM:
Employer Representative
Date
REASON FOR LEAVE
On
Date Request Received
you requested FML leave from
to
Start Date
for:
End Date
y o u r own serious health condition
-birth of child, bonding with newborn child, or placement o f child with you for adoption or foster care
-care o f your -spouse -domestic partner
child
parent
child o f your
domestic partner who has a serious health condition
-a qualifying exigency arising out ofthe fact that your -spouse -son or daughter
-parent is on active duty or has been notified o f an impending call or order to active duty in
support o f a contingency operation
c a r e ofyour -spouse s o n or daughter
domestic partner
child ofyour
domestic partner -parent -next o f kin who is a covered servicemember with a
serious injury or illness
ELlClBlLlM
Y
o
u are eligible for FML leave.
-You are not eligible for FML leave, because you:
-
have not been employed by Metro for over one year.
1
(Hire date:
- have not worked at least 1,250 hours in last twelve months from start of leave.
(Actual hours worked:
-
1
have exhausted all your FML leave entitlement in the applicable 12-month period.
Page 1 o f 2
Attachment 4
APPROVAL
Your FML leave request is approved and will be counted against your FML leave entitlement.
Additional information is needed to determine if your FML leave request can be approved. The
additional information listed below must be submitted within 15calendar days from receipt o f this
notice or your leave may be denied.
-Certification o f Health Care Provider you have provided is not sufficient t o determine your
eligibility for FML. Please provide the following information:
-Please provide proof o f birth, adoption or foster care placement.
-Please provide documentation to establish the relationship between you and your
family member.
Other:
Your FML leave request is not approved because:
Y
o
u are not eligible for FML leave.
Your absence does not qualify for FML leave.
T
h
e certification/additional information you submitted t o support your request for FML
leave was not received within 15 calendar days from receipt ofthe notification.
DESIGNATION
Your leave is being designated as FML leave and will count towards your FML leave entitlement because:
Your health care provider states that you cannot return t o your usual and customary job.
Y o u r condition appears t o qualify for leave under FMLAICFRA as a serious health condition.
Your rights and responsibilities for FMLAICFRA are described in the Family Medical Leave Policy HR #33.
You may be eligible for u p t o 12 weeks o f unpaid leave i n a rolling 12-month period.
Page 2 o f 2

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