b. Personnel policy amended (FMLA)

SUIiJIC'I': FAMILY MtDICJIL I.I?AV~; 11C'I' (F) 5 . G r.' I7AGE; 15 GF i9 Certifi.catior; of. Health Care Pravi.der far Family Member's 5etous Healt}s Conciitars (Family acrd Medical heave Act) Section I: For completion by the EMPLOYEE - TNSTRUCTTONS to the EMPLOYER: 'I'lre Family acrd Medical Iaeave Act tFMI..Ft} px~avides ttrat an employer may require an emplayee seeking FMT,A px'otecti.ons because of a need for leave to care for a covered Tamil}r member with a serious health conditions to submit a medical certification issued. by the health care provider of the covered family member. Please complete Section 7 before giving this form to your employee. Yaur resparsse is volusst:ary. wYrile you are not required to use this farm, you may trot ask the employee:. to pravid.e mor.'e irsfannati.on than allawe,~d under the-, FMLfi regulaCi.orrs, 29 C.F.ft. §§ 825.306_.825.308. Iamployers must, generally maintain records and documents relatz.srg to medical. cextificatnzs~>, recert.ificatiorrs, or medical histories of employeo.a' family members, created far FMI,A purposes as conf.iclential medics;. records in separate fi.leslrecards from tkre usual. persarrnel files anc3 in accordance witYr 29 C.F.R. § 163tf.1~1(c) (1), if tyre Amex°icans with LliC;ak~.ili.t.ia=s Act. appl.ie:3. Employer nama anti contact: Cass County Government Department Head; (Department Head Signature) Section II: For completion by the EMPLOYEE - INSTRUCTIONS to the EMPLOYEE: Please complete 5ect.ion IT before giving this form t..a your. fasnil}7 rnernber ax~ Yris/Yser medical px•avider. 7'he FML71 permits an:i employer to require that you submit a timely, complete, and sufficient: medical certification to suppoxt a request for FMLA leave to care fas: a covered family member with a serious healttr condit:iors, Zf requested by yraur. emp:l.ayer, your respansc~ i> requ.ired to obtain or ret.a:Grr the benefit at FMI,F1 protecCions. 23 U.S.C. §§2Ei13,2631i(c) t3). F'ailurE to provi::le a c.•omplete and sufficient medical cer.-tificati.on nsr~y .t:°t~:ult. its a denial or. your FMI,A r.-equest. 29 C.F.R. § 82.5.31.3. Yaur employer must give you at lE>ast 15 cal~rrdar days to return this fozm to your employer. 29 C.F.f2. § 82'i.3US Ycsur name First _• _. Middle Last Narrse of family member far wiLnm ynu will pxavide cane: f• r rst Ma.ddle I,a~t Relationship af. facn ly arember to you: If family member .is your son ax' daughter, date of birth: