CCR2009116-Policy-FMLA-Attachment
Family & Medical Leave Act (FMLA)
Resolution #116 -2009
Effective August 11, 2009
I. PURPOSE
This policy outlines the provisions of the federal and Wisconsin Family and Medical Leave Acts and the rights and
obligations of employees under both laws.
II. POLICY
The Family and Medical Leave Act (FMLA) provides eligible employees with up to 12 work weeks of protected
leave each year for specified family and medical reasons. A “calendar year” is designated under Wisconsin FMLA
law. The FMLA seeks to accomplish these purposes in a manner that accommodates the legitimate interests of
employers and minimizes the potential for employment discrimination.
Note: The eligibility and entitlements are defined differently under Federal and State law. This policy reflects
Federal law; however, if an employee is eligible for provisions in the State law, these will be discussed with each
individual separately. Federal and State law will run concurrently.
III. ELIGIBILITY
Employees are entitled to FMLA benefits if they:
Federal - Have been employed by the City of Muskego for at least 12 months; and have worked at least 1,250
hours during the 12 months prior to the start of the FMLA leave (Time spent on paid or unpaid leave does not count
in determining the 1,250 hour eligibility).
State - Have been employed by the City for at least 52 consecutive weeks and have worked for at least 1,000 hours
during the 52 weeks prior to the start of the FMLA leave.
IV. FMLA Qualifying Events and Amount of Leave
Eligible employees may take up to a total of 12 workweeks of FMLA leave in a calendar year for the following
qualifying events:
The birth of a child and to care for the newborn child; (Use U.S. Department of Labor form WH-380-F,
Certification of Health Care Provider for Family Member’s Serious Health Condition)
The placement with the employee of a child for adoption or foster care and to care for the newly placed
child; (Use U.S. Department of Labor form WH-380-F, Certification of Health Care Provider for Family
Member’s Serious Health Condition)
To care for the employee’s spouse, child, (Care for a child does not include the children of the employee’s
domestic partner) domestic partner, or parent (including a parent-in-law and a domestic partners’ parents,
under the Wisconsin FMLA) with a serious health condition (Note: Under Wisconsin FMLA, an employee
may take up to 2 work weeks for a parent-in-law and a domestic partners’ parents); (Use U.S. Department of
Labor form WH-380-F, Certification of Health Care Provider for Family Member’s Serious Health
Condition)
Family leave due to an employee’s spouse, child, (Care for a child does not include the children of the
employee’s domestic partner), domestic partner (under Wisconsin FMLA) or parent (includes a parent-in-
law and domestic partners’ parents under the Wisconsin FMLA) being on exigent active duty or having been
notified of an impending call or order to exigent active duty in the Armed Forces in support of a contingency
operation; (Use Department of Labor form WH-384, Certification of Qualifying Exigency for Military
Family Leave)
For the employee’s own serious health condition that renders the employee unable to perform his/her job.
(Use Department of Labor form WH-380-E, Certification of Health Care Provider for Employee’s Serious
Health Condition)
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For the employees’ own serious injury or illness incurred as a service member. (Use Department of Labor
form WH-385, Certification for Serious Injury or Illness of Covered Service member for Military Family
Leave)
Twelve weeks of family leave can be utilized by an employee whose spouse, child, or parent has been called to
exigent active duty to make arrangements for child care, make financial and legal arrangements, attend counseling,
attend official ceremonies or programs where the military requests participation of the family member, to attend to
farewell or arrival arrangements, or to attend to affairs caused by the missing status or death of a service member.
Eligible employees may take up to a total of 26 work weeks of FMLA leave in a calendar year to care for a spouse,
child, parent, or next of kin who is a member of the Armed Forces who suffered an injury or illness while on active
duty that renders the person unable to perform the duties of the member’s office, grade, rank, or rating.
If an employee takes paid sick leave for a condition that progresses into a serious health condition, the City may
designate all or some portion of the related leave as taken under this policy to the extent that the earlier leave meets
the necessary qualifications.
Leave qualifying for both Wisconsin and Federal FMLA leave count against an employee’s entitlement under both
laws and will run concurrently. Qualified leave taken under Worker’s Compensation will also run concurrently with
Federal FMLA leave.
Leave Duration
An eligible employee can take up to twelve (12) workweeks of leave during any twelve (12) month period. The City
will calculate the twelve (12) month period for the calendar year. Each time an employee takes FMLA qualified
leave, the City will compute the amount of leave the employee has taken under the policy and subtract it from the
twelve (12) weeks of leave available, and the balance remaining is the amount the employee is entitled to take at that
time.
Husband & Wife
If a husband and wife both work for the City and each wishes to take a leave for the birth, adoption, or placement of
a child, or to care for a parent (not parent-in-law), the husband and wife, combined, may only take a total of twelve
(12) weeks of leave. In the case of a child with a serious health condition, 12 weeks of FMLA leave for each parent
is allowed.
Non-continuous or Intermittent Leave
Employees are permitted to take leave on an intermittent (blocks of time) or reduced work schedule:
When it is medically necessary to care for a family member with a serious health condition or because of the
employee’s serious health condition;
When it is necessary to care for a family member or next of kin who suffered an injury or illness while on
active duty;
To care for a newborn, adopted or foster child. Federal FMLA leave for the birth or placement of a child for
adoption or foster care may not be taken in non-continuous increments unless approved by the City. Under
the Wisconsin FMLA, the last increment of leave for the birth or adoption of a child must begin within 16
weeks of that birth or placement.
Medical or family caretaking leave should be planned so as not to unduly disrupt the City’s operations.
The City allows for intermittent leave to be taken in no less than one hour increments or, under certain
circumstances, may use the leave to reduce the work week or work day, resulting in a reduced hour schedule.
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Federal/State run concurrent when the reasons for the leave are the same, but in cases where there are different
reasons for leave within 1 year, an employee may go over 12 weeks (i.e. employee is off for a surgery for 12 weeks
and has a baby later that same year – the employee would be entitled to 6 weeks for birth of a child, assuming the
surgery was unrelated to the pregnancy and outside the 16 week window).
When requesting an intermittent leave or reduced work schedule, the City AND employee must mutually agree to
the schedule before the leave begins. If this is not possible, the employee must prove the use of the leave is
medically necessary.
Requesting a Leave
An employee requesting leave under this policy must complete a City of Muskego Family and Medical Leave of
Absence Request Form and forward it to the Human Resources Coordinator.
The employee must request the leave at least 30 days in advance. If it is not possible to give 30 days notice, the
employee must give as much notice as practicable. An employee undergoing planned medical treatment is required
to make a reasonable effort to schedule the treatment to minimize disruptions to the City’s operations.
If an employee fails to provide 30 days notice for foreseeable leave with no reasonable excuse for the delay, the
leave request may be denied until at least 30 days from the date the City receives the notice.
While on leave, employees are required to report periodically to their supervisor regarding the status of the medical
condition and their intent to return to work.
Certification of the Serious Health Condition
If the requested leave is for a family member’s or the employee’s serious health condition, the employee must
submit a medical certification from the employee’s or the family member’s health care provider. See Section IV
titled: FMLA Qualifying Events and Amount of Leave for the list of qualifying events and corresponding form to
use. The employee must respond to this requirement within fifteen (15) days or provide a reasonable explanation for
the delay.
The city also reserves the right, once the leave begins, to ask for the attending physician to complete a City of
Muskego Family and Medical Leave Health Care Provider Certification form periodically regarding the employee’s
status and intent to return to work.
If the employee plans to take intermittent leave or work a reduced work schedule, the certification must also include
dates and the duration of treatment and a statement of medical necessity for taking an intermittent leave or work a
reduced schedule.
The City has the right to ask for a second opinion if it has reason to doubt the certification. The City of Muskego
Family and Medical Leave Request Health Care Provider Certification form will be used for this purpose. The City
will pay for the employee to get a certification from a second physician, which the City will select.
If necessary to resolve a conflict between the original physician and second opinion, the City will require the
opinion of a third physician. The City and employee will jointly select the physician and the City will pay for the
opinion. This third opinion will be considered as binding and final.
Use of Paid or Unpaid Leave
Under Wisconsin law, an employee has the option to substitute accrued, but unused vacation, personal leave,
compensatory time or sick leave to remain in a paid status. However, under Federal law, the city may require
substitution of vacation, personal leave, compensatory time or sick leave.
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The city will allow an employee to take up to 2 weeks (10 days) of unpaid leave. For the remainder of the leave, the
city will require the substitution of accrued vacation, personal leave, compensatory time and/or sick time. (More
than one event could happen in one year and could go over the 10 days).
Employment Status & Benefits During the Leave
While the employee is on leave, the City will continue the employee’s benefits governed by either his/her labor
contract or non-rep benefit resolution.
Other benefit deduction(s): While on paid leave, benefit deductions will continue through payroll deductions.
While on an unpaid leave, the employee is responsible for the payment of other benefit premiums when required.
City benefits may be continued during periods of unpaid FMLA leave and arrangements should be made for
employee’s portion of the payments with the Finance Director.
Employment Status After the Leave
An employee who takes leave under this policy will be able to return to the same job or to a job with equivalent
status, pay, benefits, and other employment terms. The position will be the same or one, which entails substantially
equivalent skill, effort, responsibility, and authority (provided employee is physically capable of performing the
job).
Return to Work
An employee returning from FMLA for his or her own serious health condition must provide a fitness for duty
certification/physician’s statement releasing the employee back to full or restricted duty. A copy of the employees’
job description should be included with the physician’s statement. If returning to restricted duty, the return to work
slip should indicate the limitations and suggested accommodations, as well as the duration of the restrictions. You
may be asked to have your physician complete an Attending Physician’s Report The Family and Medical Leave Act
Form, which allows your physician to be specific on the restrictions.
V. Definitions
A. Child
Biological, adopted, or foster child, stepchild, legal ward or, under the federal FMLA, the child of a person
having day-to-day care of the child, or a child of a person standing “in loco parentis,” who is under 18 years of
age or 18 years of age and older and incapable of self-care because of a serious health condition.
B. Covered Service member (Federal FMLA)
A current member of the Armed Forces, including a member of the National Guard or Reserves, who is
undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the
temporary disability retired list, for a serious injury or illness.
C. Domestic Partner (Wisconsin FMLA)
Same-sex couples who register in their county of residence and same-sex and opposite-sex couples who are
not required to register
1. To qualify as registered domestic partners, two individuals must meet the following criteria: at least 18
years of age and capable of consenting to the relationship, not married to, or in a domestic partnership with
another individual, not more closely related than second cousins (whether of the whole or half blood or by
adoption), they must share a common residence, and be members of the same sex.
2. To qualify as domestic partners without registration, two individuals must meet the following criteria: at
least 18 years of age and capable of consenting to the relationship, not married to, or in a domestic
partnership with another individual, they must share a common residence, they must not be related
by blood in a way that would prohibit marriage under Wis. Stat. 763.03, they must consider themselves to
be a member of each other’s immediate family; and they must agree to be responsible for each
other’s basic living expenses.
D. Incapable of Self-Care
The individual requires active assistance or supervision to provide daily self-care in three or more of the
activities of daily living (i.e. grooming, hygiene, bathing, dressing, eating) or instrumental activities of daily
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living (i.e. cooking, cleaning, shopping, utilizing public transportation, paying bills, maintaining a residence,
using telephones and directories, and using a post office).
E. Next of Kin (Federal FMLA)
The nearest blood relative other than the covered service member’s spouse, parent, son or daughter, in the
following order of priority: Blood relatives who have been granted legal custody of the covered service
member by court decree or statutory provisions, brothers and sisters, grandparents, aunts and uncles, and first
cousins, unless the covered service member has specifically designated in writing another blood relative as his
or her nearest blood relative for purposes of military caregiver leave under the FMLA. When no such
designation is made, and there are multiple family members with the same level of relationship to the covered
service member, all such family members shall be considered the covered service members’ next of kin and
make take FMLA leave to provide care to the covered service member, either consecutively or simultaneously.
When such designation has been made, the designated individual shall be deemed to be the covered service
member’s only next of kin.
F. Parent
Biological parent, foster parent, adoptive parent, stepparent or legal guardian of an employee, or parent-in-law
or domestic partners’ parents under the Wisconsin FMLA. Under the federal FMLA, “parent” includes an
individual who provided day-to-day care to the employee when the employee was a child.
G. Serious Health Condition
An illness, injury, impairment or physical or mental condition that involves:
1. Inpatient care in a hospital, hospice or residential medical care facility; or
2. Under Wisconsin FMLA, outpatient care that requires continuing treatment or supervision by a health care
provider (generally defined as requiring two direct, continuous and first hand contacts by a health care
provider); or
3. Under the federal FMLA:
a. A period of incapacity of more than 3 consecutive, full calendar days, and any subsequent treatment or
period of incapacity relating to the same condition, that also involves:
i. Treatment two or more times, within 30 days of the first day of incapacity, unless extenuating
circumstances exist, by a health care provider, by a nurse under direct supervision of a health care
provider, or by a provider of health care services (i.e. physical therapist) under orders of, or on
referral by, a health care provider; or
ii. Treatment by a health care provider on at least one occasion, that results in a regimen of
continuing treatment under the supervision of a health care provider.
The first or only in person treatment visit must take place within seven days of the first day of
incapacity.
The health care provider shall determine whether additional visits or a regimen of continuing
treatment is necessary within the 30-day period.
b. Any period of incapacity due to pregnancy or for prenatal care;
c. Chronic conditions requiring periodic treatment (defined as at least twice a year) by or under the
supervision of a health care provider that continue over an extended period of time and may cause an
episodic rather than a continuing period of incapacity (i.e. asthma, diabetes, epilepsy, etc.);
d. Permanent/long term conditions requiring supervision for which treatment may not be effective (i.e.
Alzheimer’s, a severe stroke, or the terminal stages of a disease);
e. Multiple treatments by or under the supervision of 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 calendar days in the absence of medical intervention or treatment, such as cancer
(chemotherapy), severe arthritis (physical therapy), or kidney disease (dialysis).
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STEPS FOR APPLYING
FOR FAMILY OR MEDICAL LEAVE OF ABSENCE
EMPLOYEE GUIDE
1. The employee should discuss the situation with his/her immediate supervisor and the Human Resources
Coordinator. The employee will be provided with the WHD Publication 1420, dated January 2009 –
Employee Rights & Responsibilities Under the Family and Medical Leave Act.
If the precipitating event is foreseeable, the employee shall notify the City thirty days prior to the
leave.
If the precipitating event was unanticipated, the employee shall notify the City as soon as practicable.
2. Complete the City of Muskego Family and Medical Leave of Absence Request form and forward it to his/her
immediate supervisor, who will then sign it and have the employee send the employee to the Human
Resources Coordinator.
All requests MUST include an anticipated start and ending date.
All requests must include the Health Care Provider certification See Section IV titled: FMLA
Qualifying Events and Amount of Leave for the list of qualifying events and corresponding form to use.
3. Human Resources will provide to the employee the Department of Labor Form WH-381, Notice of
Eligibility and Rights & Responsibilities – Family and Medical Leave Act and Department of Labor Form
WH-382, Designation Notice for Family and Medical Leave Act, confirming the approval/denial of the
leave.
4. The employee is responsible for notifying his/her immediate supervisor AND Human Resources of any
changes of dates in his/her leave status.
5. The leave cannot exceed the physicians’ certification. If needed, the physician must recertify the existing
condition. The employee is responsible for providing recertification of status if applicable. The same form
may be recertified or a new form may be executed. See the Human Resource for additional forms.
6. The employee is responsible for providing evidence of fitness for duty to certify the employee is capable of
returning to work with restrictions or full duty. Complete the Attending Physician’s Report The Family And
Medical Leave Act. Delays in turning in this certification may result in delays in returning the employee to
duty and pay status.
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CITY OF MUSKEGO
FAMILY AND MEDICAL LEAVE OF ABSENCE REQUEST FORM
Name: ________________________________ Department: ____________________________
Position: __________________________ Phone Number: ( ) _____________cell ( ) __________
I request a leave as provided by the Family and Medical Leave Act for the following period:
Anticipated Leave Start Date: ________________ Anticipated End Date: ___________________
The leave is requested for the following reason(s):
1. ______ The birth of my son or daughter and to care for such child;
2. ______ The placement of a child for adoption or foster care and to care for such child;
3. ______ To care for my spouse, son, daughter, or parent (circle one) who has a serious
Health condition; reason ____________________________________________
4. ______ My spouse, child or parent (circle one) being on or ordered to active duty
5. ______ My serious health condition; reason __________________________________
If items 1 or 2 above: Intermittent leave can only be used within 16 weeks before or after the birth or adoption and
is subject to the City’s approval.
I request to substitute the following days:
______ Unpaid leave days ______ days
______ Sick leave days ______ days
______ Vacation days ______ days
(Note: The substitution of the aforementioned days for family or medical leave will not extend or result in additional
family or medical leave. Under Federal law, the City of Muskego may require substitution of paid time during the
length of the leave).
RETURN TO WORK CERTIFICATION: I understand that if I am requesting medical leave for my serious health condition, I must not
only provide the City of Muskego with a certification from my health care provider as to the existence of my serious health condition, but must also
provide the City of Muskego with a Return to Work Certification which has been completed by my physician. I understand that failure to provide the
Return to Work Certification may result in my being denied reinstatement until such document is provided to the Human Resources. In the event that I
desire to return to work prior to the expiration of my leave, I will notify the City at least two (2) business days prior to my desired return date.
CHECK ONE BY THE SUPERVISOR IF CERTIFICATION IS REQUIRED ______YES ______NO
ALTERNATIVE POSITION DURING LEAVE: I understand and agree that if my leave is requested to be taken on a reduced or
intermittent basis and I am capable of performing work during my requested leave, the City may place me in alternative employment within the City and I
hereby agree to such placement. I understand that the position that I may be placed in is only temporary. I will be returned to my position or substantially
equivalent employment upon expiration of my leave (providing I am physically capable of performing the functions of the position).
If you are requesting intermittent or reduced leave, please provide a schedule of the leave to your supervisor and coordinate work schedules.
Date _____________________ Employee Signature ________________________________________
Supervisor Acknowledgement _______________________________________ Date ______________
Date Received _________ Human Resources Signature ______________________________________
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CITY OF MUSKEGO
FAMILY AND MEDICAL LEAVE REQUEST
nd
HEALTH CARE PROVIDER CERTIFICATION (For a 2 Opinion)
Employee Name: __________________________________________
I, ___________________________________________, certify that _______________________________________ has a
(Health Care Provider) (Patient)
1) ‘Serious health condition’ which is an illness or injury, impairment or physical or mental condition. The following are the definitions of
a ‘Serious Health Condition’ under the Family and Medical Leave Act. Please indicate what category, if any, applies to this patient’s
condition:
___ A) Inpatient care in a hospital, hospice, or residential medical facility
___ B) Absence Plus Treatment (A period of incapacity of more than three consecutive calendar days that also involves one of
The following circumstances (please mark appropriate line):
___ Treatment two or more times by a health care provider; OR
___ Treatment by a health care provider on at least one occasion, which results in a regimen of continuing treatment.
(May include course of prescription medication or therapy requiring special equipment. Does not include
Over-the-counter medications, bed-rest, exercise, or other activities which can be initiated without a visit to a
Health care provider).
___ C) Pregnancy
___ D) Chronic Condition Requiring Treatment. (Condition must involve all of the following circumstances):
- Requires periodic visits for treatment by a health care provider; and
- Continues over an extended period of time (recurring episodes of single underlying condition); and
- May cause episodic rather than a continuing period of incapacity (asthma, diabetes, epilepsy, etc.).
___ E) Permanent/Long-term Conditions Requiring Supervision: A period of incapacity resulting from a permanent or long-term
Condition for which patient must be under continuing supervision of, but not be receiving active treatment by a health care
Provider (Alzheimer’s, severe stroke, terminal stages of a disease, etc.).
___ F) Multiple Treatments (Non-chronic Condition): Any period of absence to receive multiple treatments by, or under the
Orders of, a health care provider, either for restorative surgery after an accident or injury or for a condition that would
Likely result in an absence of three or more consecutive calendar days in the absence of the treatment, such as cancer
(Chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis), etc.
___ G) None of the above categories apply to this patient’s condition.
2) Describe the medical facts which support your certification above including a brief statement as to how the medical facts meet the
criteria of the category indicated above:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
3) Date condition commenced: ________________ Probable duration of the condition: _____________
Is the patient presently incapacitated? ____ Yes ____ No. If ‘yes’, probable duration of patient’s present incapacity?
_________________________________________________________________________________________________________
4) If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments:
_________________________________________________________________________________________________________
If the patient will be absent from work or other daily activities on an intermittent or part-time basis because of treatment(s) also
Provide an estimate of the probable number and interval between such treatments, actual or estimated dates of treatment (if
known), and period required for recovery, if any:
_________________________________________________________________________________________________________
If any of these treatments will be provided by another provider of health services (i.e., physical therapist, etc.), please state the
nature of such treatments:
__________________________________________________________________________________________________________
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If this certification is related to care for the employee’s seriously ill family member, please skip the next question and proceed to
question 6.
5) If medical leave is required because of the employee’s own condition (including absences due to pregnancy or a chronic condition),
please answer the following questions:
Yes No
a) ___ ___ Is the employee unable to perform work of any kind?
b) ___ ___ If able to perform some work, is the employee unable to perform any one or more of the essential functions of the
employee’s job (the employee or the employer should supply information about the essential job functions)? If
‘Yes’, please list the essential function(s) the employee is unable to perform: _______________________________
_____________________________________________________________________________________________
c) ___ ___ Will it be necessary for the employee to work less than a full schedule or to take leave on an intermittent basis as a
result of the condition? If ‘yes’, give the probable duration_____________________________________________
d) ___ ___ If neither a or c applies, is it necessary for the employee to be absent from work for treatment?
6) A) ___ ___ If leave is required to care for a family member with a serious health condition, does the patient require assistance
For basic medical, hygiene, nutritional needs, safety, or transportation?
b) ___ ___ If response to a above is ‘no’, is the employee’s presence necessary to provide psychological comfort to the patient
And assist in the patient’s recovery?
c) ___ ___ If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this
Need: ________________________________________________________________________________________
_______________________________________________________________________________________ Phone: __________________
Name and Address of Health Care Provider (please print or stamp)
____________________________________________________________ ___________________ Type of Practice: _____________
Signature of Health Care Provider Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
*
To be completed by the Employee Requesting 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, including a schedule if leave is to be taken
intermittently or if it will be necessary for you to work less than a full schedule:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________ ___________________________
Employee’s Signature Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
*
AUTHORIZATION TO RELEASE INFORMATION: TO BE SIGNED BY THE PATIENT (PARENT OR GUARDIAN IF
PATIENT IS A MINOR).
I authorize the release of any medical information necessary to process the above request.
________________________________________________________ ____________________________
Signature of Patient (parent or guardian if patient is a minor) Date
Important Notes and Definitions
1) For purposes of this form, the information sought relates only to the condition for which the employee is requesting FMLA leave.
2) ‘Incapacity’ for purposes of FMLA is defined to mean inability to work, attend school, or perform other regular daily activities due
to a serious health condition, treatment therefore, or recovery there from.
3) ‘Treatment’ includes examinations to determine if a serious health condition exists and evaluations of the condition. ‘Treatment’
does not include routine physical exams, eye exams, or dental exams.
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ATTENDING PHYSICIAN’S REPORT
THE FAMILY AND MEDICAL LEAVE ACT
This is to certify that ______________________________________________________
(Name of Employee)
Please check appropriate box:
No longer suffers from a serious health condition or disability and is able to work and perform all of the
functions of his/her position without restriction as of _____________________(Date). A copy of the
employee’s job description is attached for your reference.
OR
May return to restricted/alternative/modified duty from ______________(date) to _______________(date).
Comments/Restriction(s)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________ ____________________
Signature of Health Care Provider Date
______________________________________________
Printed Name of Health Care Provider:
Completed form should be returned to:
FAX Confidential materials to: (262) 679-5630
Or Mail to:
City of Muskego
Attention: Human Resources Department
P.O. Box 749
Muskego, WI 53150-0749
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FAMILY MEDICAL LEAVE CHECKLIST
Administrative Procedure
1. When a supervisor becomes aware of an employee’s potential need for FMLA, the employee should be sent
to Human Resources to pick up:
A copy of WHD 1420 Employee Rights & Responsibilities under the Family Medical Leave Act
A WH form that corresponds with the employees’ situation. See Section IV for a list of qualifying
events and corresponding forms to use.
2. The employee must submit the City of Muskego Family and Medical Leave of Absence Request form to
his/her immediate supervisor for signature then return the form to Human Resources at least 30 days in
advance of the leave. If it is not possible to give 30 days notice, the employee must give as much notice as
practicable.
3. Before the Human Resources office responds to the request, Human Resources will:
o Determine if the employee is eligible for the leave.
The employee must have been actively employed by the City for the last twelve (12) months
and worked no less than 1,250 hours during the 12-month period.
4. Human Resources, upon request for leave, will complete a WH-381 and WH-382 and forward a copy to the
employee, the finance supervisor and the employees’ supervisor. This response will outline all of the
specifics regarding the leave.
5. For leaves longer than thirty (30) days, the employee will be required to provide continuing certification
every 30 days. The employee’s supervisor should contact Human Resources when the employee is reaching
30 days so that the appropriate forms can be forwarded to the employee.
6. An employee returning from a leave must turn in a fitness for duty certification from the attending physician.
An employee’s physician to document a return with restrictions or authorize full status return to work can
utilize the Attending Physician’s Report.
7. Each supervisor should develop a tracking system to ensure that all of the proper documentation is sent.
Track dates when the medical certification was sent and received, any attending physician’s report request
and response, and forward all return to work items to Human Resources.
8. If a supervisor becomes aware of an employee who might be eligible for FMLA, but has not requested the
leave, notify Human Resources so that information can be forwarded to that employee AND when in doubt,
call Human Resources.
______________________________________________ __________________________________
John R. Johnson Date
Mayor
S:\\Cityhall\\Masters\\Employee Policy Manual\\Family Medical Leave Act cl 8/11/2009
Revised 8/11/2009
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