Admin order 44-11-05 - Laserfiche WebLink

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® Employee's Serious Health Condition ` 1, ct�14) �4�# �t( r' a. �ll 9tli `¢!'�LkitY!`C�!C�4�lttk�alpl n �al igrfst�r�t�istllo�e, 4= ii_ r" � ,tsrl!�G��..�'d.,`E3,�'.��.. ❑� Please refer to the Famitv & Medical Leave Guide for more information on Family & Medical Leave for Workers' Compensation claims 0 Care of Family Member with Serious Health Condition • Family member's relationship to employee: • If family member is a child, is child under age 18 or mentally or physically disabled? ❑- Yes ❑- No Please refer to the Family & Medical Leave Guide for a list of all FMLA and OFLA qualifying family members. 0 Birth of a Child /Adoption or Placement for Adoption of a Child (Parental Leave): • Anticipated due date: or Anticipated date of physical custody of child: • Is leave requested on an intermittent basis? ❑No ❑Yes (if yes, a Parental Leave form is required of all EPD and Fire employees) ® Pregnancy (any period of disability due to pregnancy, absences for prenatal care, or recovery from childbirth) * Anticipated due date: ® Servicemember Family Leave (to care for a member of the armed forces who is undergoing medical treatment, recuperation, or therapy for a serious illness or injury that was incurred in the course of active duty) b Qualifying Exigency Leave (OMFLA) (leave in relation to a spouse, son, daughter, or parent who is on active duty or has been notfied of an impending call or order to active duty, in support of a contingency operation for the National Guard or Reserves only) ® Leave for Victims of Domestic Violence, Sexual Assault or Stalking (Leave for the victim or the parent or guardian of victim who is a minor child) ® OFLA Non - serious Sick Child Leave (an illness crinjury that requires home care but is not a serious health condition) (REQUIRED Name of the Medical Condition: On the back side of this sheet is a description of various "serious health conditions" categories that will qualify under the Family & Medical Leave Acts. Please check the category(s) that apply to your situation: ❑ Hospital Care /Inpatient ❑ Pregnancy /Prenatal Care ❑ Perm. /Long Term Cond. Requiring Supervision Fj None of the Conditions Listed Apply Name: Date: Date received by Benefits Program: DOH: O • Hrs1Wc D Total Reg. His. Worked in last 12 Months: Eligible Family Member: DYes ONO ON/A • FMLA10FLA Coded Last 12 Months: Eligible for:. DFMLAI0FLA OOFLA ONLYI OFMLA ONLYI Date Supervisor Contacted: • Medical Certification Requested? O Yes D No D NIA ( ) O PROVISIONAL SENT: O FINAL APPROVAL SENT: O DENIAL SENT: Absence Plus Treatment Chronic Condition Requiring Treatment Mult. Treatments (non- chronic cond.) Other: Send original to • Risk Services Benefits Program • 101 E. Broadway, Suite 450 o Eugene OR 97401 • Fax: (547) 682 -5211 e Rev. 7 /22/10