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<br />SUBJECT: AMERICANS WITH DISABILITIES ACT (II ADA II ) <br /> <br />6.02 <br /> <br />PAGE 6 OF 6 <br /> <br />Employer Response to Employee <br />Request for Family or Medical Leave <br />(Family and Medical Leave Act of 1993) <br /> <br />(Date) <br /> <br />TO: <br /> <br />(Employee's Name) <br /> <br />FROM: <br /> <br />(Name of Appropriate Employer Rep.) <br /> <br />SUBJECT: (Request for Family/Medical Leave) <br /> <br />On , you notified us of your need to take family/medical <br />(date) <br />leave due to: <br />the birth of a child, or the placement of a child with you for <br />adoption or foster care; or <br />a serious health condition that makes you unable to perform the <br />essential functions of your job; or <br />a serious health condition affecting your _Spouse,_Child, <br />Parent, for which you are needed to provide care. <br />You notified us that you need this leave beginning on <br />(date) <br />and that you expect leave to continue until on or about <br />(date) <br />Except as explained below, you have a right under the FMLA for up to 12 weeks of <br />unpaid leave in a 12-month period for the reasons listed above. Also, your health <br />benefits must be maintained during any period of unpaid leave under the same <br />conditions as if you continued to work, and you must be reinstated to the same or <br />an equivalent job with the same pay, benefits, and terms and conditions of <br />employment on your return from leave. If you do not return to work following <br />FMLA leave for a reason other than: (l)the continuation, recurrence, or onset of <br />a serious health condition which would entitle you to FMLA leave; or (2) other <br />circumstances beyond your control, you may be required to reimburse us for our <br />share of health insurance premiums paid on your behalf during your FMLA leave. <br /> <br />This is to inform you that: (check appropriate boxes; explain where <br />indicated) <br />1. You are Eligible Not eligible for leave under the FMLA. <br />2. The Requested leave will ____ will not be counted against your <br />annual FMLA leave entitlement. <br />3. You will Will not be required to furnish medical <br />certification of a serious health condition. If required, you must <br />furnish certification by (Insert date) (must be at least 15 <br />days after you are notified of this requirement) or we may delay the <br />commencement of your leave until the certification is submitted. <br />