"Fmla/Ada Check List" - Florida

Fmla/Ada Check List is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Rick Scott, Governor
Christina K. Daly, Secretary
FMLA/ADA Check List*
When submitting a request for termination based on Inability to Perform,
please check mark and answer the following questions:
Name of Employee:
Date:
1.
What is the DATE the employee exhausted his/her FMLA entitlement?
D
:
ATE
2.
What is the POSITION HELD and the NAME OF THE FACILITY for the
Employee?
P
H
:
OSITION
ELD
N
F
:
AME OF
ACILITY
3.
What are the NUMBER OF VACANCIES at that facility/unit?
4.
Does the employee have TIME ON THE BOOKS to receive his/her own
paid leave?
5.
Would the EXTENDED ABSENCE from work after the FMLA entitlement be
an Undue Hardship on the facility given your vacancies and the operation
of your facility?
400 W. Robinson Street, S1009
Orlando, Florida 32801
(407) 428-5902
http://www.djj.state.fl.us
The mission of the Department of Juvenile Justice is to increase public safety by reducing juvenile delinquency through effective
prevention, intervention, and treatment services that strengthen families and turn around the lives of troubled youth.
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Rick Scott, Governor
Christina K. Daly, Secretary
FMLA/ADA Check List*
When submitting a request for termination based on Inability to Perform,
please check mark and answer the following questions:
Name of Employee:
Date:
1.
What is the DATE the employee exhausted his/her FMLA entitlement?
D
:
ATE
2.
What is the POSITION HELD and the NAME OF THE FACILITY for the
Employee?
P
H
:
OSITION
ELD
N
F
:
AME OF
ACILITY
3.
What are the NUMBER OF VACANCIES at that facility/unit?
4.
Does the employee have TIME ON THE BOOKS to receive his/her own
paid leave?
5.
Would the EXTENDED ABSENCE from work after the FMLA entitlement be
an Undue Hardship on the facility given your vacancies and the operation
of your facility?
400 W. Robinson Street, S1009
Orlando, Florida 32801
(407) 428-5902
http://www.djj.state.fl.us
The mission of the Department of Juvenile Justice is to increase public safety by reducing juvenile delinquency through effective
prevention, intervention, and treatment services that strengthen families and turn around the lives of troubled youth.
FMLA/ADA Check List
Page 2 of 2
6.
Have you referred the employee to PEOPLE FIRST to inquire as to other
open job positions available for which the employee may minimally qualify
given his/her medical condition? If found, WHAT IS THE POSITION?
P
F
:
OSITION
OUND
7.
What is the MEDICAL CONDITION of the employee that is preventing
him/her from working?
8.
What is the ANTICIPATED DATE of full recovery of the employee?
D
:
ATE
9.
Has the employee requested an ACCOMMODATION? If so, what is being
requested?
Keep in mind you do not have to create a position which does not exist.
Liaison Signature
* This form, completed and the supporting documentation, MUST be
sent with the Disciplinary Request Package for Inability to Perform.
Page of 2