Notice to Employee concerning Family Medical Leave Eligibility

CODE: GBN-R2

Maine School Administrative District No. 31

NOTICE TO EMPLOYEE CONCERNING FAMILY MEDICAL LEAVE ELIGIBILITY

TO: ____________________________________

(Employee's Name)

FROM: ____________________________________

(Name of appropriate employer representative)

SUBJECT: Family Medical Leave Eligibility

DATE: ____________________________________

Federal FMLA Benefits

Except as explained below, you have a right under the Federal FMLA for up to 12 weeks of unpaid leave in a 12-month period for the reasons listed in paragraph 1 below. Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work and 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 leave if you return on or before the expiration date of your leave. If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave; or (2) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA leave.

Maine FMLA Benefits

If you are not eligible for leave under the Federal FMLA, you may be eligible for leave under the Maine Family Medical Leave law. If so, you have a right under the Maine FMLA to up to 10 consecutive weeks of unpaid leave in a two-year period for the reasons listed in paragraph 1 below (except for foster care of a child). Under the Maine FMLA, you may continue your group health insurance benefits, if any, at your own expense during the leave period. 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 leave if you return on or before the expiration date of your leave.

1. On , we became aware that you may be entitled to Family Medical Leave due to:

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

a serious health condition that makes you unable to perform the essential functions of your job;

or a serious health condition affecting your

spouse,

child,

parent, for which you are needed to provide care.

Your period of leave is expected to begin on and continue until on or about .

2. Based on the information we have at this time, we have determined that you are

eligible for Federal Family Medical Leave. No further certification is required.

eligible for Federal Family Medical Leave subject to receipt of adequate medical certification

(see paragraph 3 below).

not eligible for leave under the Federal FMLA, but you are eligible for leave under the Maine State

FMLA, subject to receipt of medical certification. Disregard paragraphs 3 through 8 and go directly

to the State FMLA provisions listed in Paragraph 9 below

not eligible for leave under either the Federal FMLA or the Maine State FMLA.

Continue with the following if the employee is or may be eligible for Federal FMLA:

3. You will will not be required to furnish medical certification of your own serious health condition or that of your

parent, spouse, or child (whichever is applicable). If required, you must furnish certification on the attached form

by or we may delay the commencement of your leave until the certification is submitted.

4. If you are also eligible for paid sick leave or other leave in accordance with the terms of applicable policies or contracts, your

FMLA will run concurrently (i.e., both at the same time) with your paid leave, unless otherwise noted (explain):

5. (a) If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of

FMLA leave. Unless other arrangements are made, you must make premium payments as follows: monthly payments in the

amount of must be delivered to the central office on or before the day of each month. We will

deduct these from your pay.

(b) You have a 30-day grace period in which to make premium payments. If payment is not made timely, your group health

insurance may be canceled, provided we notify you in writing at least 15 days before the date that your health coverage will

lapse. 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 health insurance premiums while you are on leave and

deduct them from your pay.]

(c) Other benefit payments, if any, that you must make while on leave, including type, amount, and due date:

6. You will will not be required to present a fitness-for-duty certificate prior to being restored to

employment. If such certification is required but not received, your return to work may be delayed until certification is provided.

7. While on leave, you will will not be required to furnish us with periodic reports every 30 days

(indicate interval of periodic reports, as appropriate for the particular leave situation) of your status and intent to return to work.

If the circumstances of your leave change and you are able to return to work earlier than the date indicated on this form,

you will will not be required to notify us at least two work days prior to the date you intend to report

for work.

8. You will will not be required to furnish recertification relating to a serious health condition every

30 (not less than 30) days. We may request medical recertification sooner if circumstances concerning your leave change

significantly or we receive information that casts doubt on the validity of the medical certification.

Further comments:

Maine State FMLA

9. If you are eligible for state FMLA, but not federal FMLA, disregard paragraphs 2 through 8 above. The Maine FMLA is different in several important ways from the federal FMLA. You have the following rights, obligations and benefits under the Maine FMLA if you have been employed for at least 12 months:

A. Up to 10 consecutive weeks of unpaid leave in a two-year period for the purposes listed above.

B. You must give 30 days notice of intended leave except in case of medical emergency.

C. You may continue your employee benefits at your own expense. The benefits you may continue and

the costs are:

Health Insurance

Payment must be delivered to the office on or before the following date(s):

D. You will will not be required to furnish medical certification of your own serious health condition

or that of your parent, spouse or child (whichever is applicable) on the attached form. The certification must be submitted

by . Your entitlement to leave is contingent upon your submitting adequate medical

certification.

E. If you are also eligible for paid sick leave or other leave in accordance with the terms of applicable policies or contracts, your family medical leave will run concurrently (i.e., both at the same time) with your paid leave, unless otherwise noted (explain):

First Reading: 12/21/2005

Second Reading: 01/25/2006

Adopted: 01/25/2006