Form NPD-62 "Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)" - Nevada

What Is Form NPD-62?

This is a legal form that was released by the Nevada Department of Administration - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Nevada Department of Administration;
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  • Fill out the form in our online filing application.

Download a fillable version of Form NPD-62 by clicking the link below or browse more documents and templates provided by the Nevada Department of Administration.

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NOTICE OF ELIGIBILITY AND RIGHTS & RESPONSIBILITIES (FAMILY AND MEDICAL LEAVE ACT)
In general, to be eligible an employee must have worked for an employer for at least 12 months and have met the hours of service requirement in the
12 months preceding the leave. A fully completed Form NPD-62 provides employees with the information required by 29 C.F.R. § 825.300(b), which
must be provided within five business days of the employee notifying the employer of the need for FMLA leave. Part B provides employees with
information regarding their rights and responsibilities for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).
PART A – NOTICE OF ELIGIBILITY
DATE: _______________________________________________________________________
TO:
_______________________________________________________________________
________________________________
(Employee’s Name)
(Employee ID #)
FROM: _______________________________________________________________________ PHONE: ________________________________
On_____________________________, you notified us/we became aware that you needed leave beginning on _____________________________ for:
(Date)
(Date)
The birth of a child, or the placement of a child with you for adoption or foster care.
Your own serious health condition.
Because you are needed to care for your
spouse,
child,
parent due to his/her serious health condition.
Because of a qualifying exigency arising out of the fact that your
spouse,
son or daughter,
parent is on covered active duty or a
call to covered active duty status with the Armed Forces.
Because you are the
spouse,
son or daughter,
parent,
next of kin of a covered servicemember with a serious injury or illness.
This Notice is to inform you that: (check appropriate boxes; explain where indicated)
You are eligible for FMLA leave. (See Part B below for Rights and Responsibilities).
You are not eligible for FMLA leave, because:
You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave, you will have worked
approximately ________ months towards this requirement.
You have not met the FMLA’s hours of service requirement.
If you have questions, contact ______________________________ or view the FMLA poster located in ____________________________________.
PART B – RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE
As explained in Part A, you meet the eligibility requirements for taking FMLA leave and still have FMLA leave available in the applicable 12-month
period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must return the following information to us
by________________________. (If a certification is requested, employers must allow at least 15 calendar days from receipt of this notice; additional
time may be required in some circumstances.) If sufficient information is not provided in a timely manner, your leave may be denied.
Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to support your
request is enclosed.
Sufficient documentation to establish the required relationship between you and your family member.
Other information needed (such as documentation for military family leave):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
No additional information requested.
If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave (only checked blanks apply):
You will be required to use your available paid leave during your FMLA absence. With the exception of the qualifying events outlined in NAC
284.5811 (i.e., workers’ compensation, short or long-term disability benefit), you will be required to exhaust all accumulated compensatory time
and all forms of paid leave time for which you are eligible prior to using leave without pay (NAC 284.5811). This means that you will receive
your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave entitlement. This absence
will involve the use of the type(s) of leave indicated.
Compensatory Time
Annual Leave
Sick Leave
Family Sick Leave
Catastrophic Leave
N/A
You are authorized to begin using FMLA leave codes on your timesheet for any leave used in conjunction with this event. If this event is
later determined not to be eligible for FMLA leave, then the agency will change these codes as appropriate and notify you of the changes.
You should use the following codes:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Notice of Eligibility and Rights & Responsibilities
NPD-62
Page 1 of 2
Rev. 9/18
NOTICE OF ELIGIBILITY AND RIGHTS & RESPONSIBILITIES (FAMILY AND MEDICAL LEAVE ACT)
In general, to be eligible an employee must have worked for an employer for at least 12 months and have met the hours of service requirement in the
12 months preceding the leave. A fully completed Form NPD-62 provides employees with the information required by 29 C.F.R. § 825.300(b), which
must be provided within five business days of the employee notifying the employer of the need for FMLA leave. Part B provides employees with
information regarding their rights and responsibilities for taking FMLA leave, as required by 29 C.F.R. § 825.300(b), (c).
PART A – NOTICE OF ELIGIBILITY
DATE: _______________________________________________________________________
TO:
_______________________________________________________________________
________________________________
(Employee’s Name)
(Employee ID #)
FROM: _______________________________________________________________________ PHONE: ________________________________
On_____________________________, you notified us/we became aware that you needed leave beginning on _____________________________ for:
(Date)
(Date)
The birth of a child, or the placement of a child with you for adoption or foster care.
Your own serious health condition.
Because you are needed to care for your
spouse,
child,
parent due to his/her serious health condition.
Because of a qualifying exigency arising out of the fact that your
spouse,
son or daughter,
parent is on covered active duty or a
call to covered active duty status with the Armed Forces.
Because you are the
spouse,
son or daughter,
parent,
next of kin of a covered servicemember with a serious injury or illness.
This Notice is to inform you that: (check appropriate boxes; explain where indicated)
You are eligible for FMLA leave. (See Part B below for Rights and Responsibilities).
You are not eligible for FMLA leave, because:
You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave, you will have worked
approximately ________ months towards this requirement.
You have not met the FMLA’s hours of service requirement.
If you have questions, contact ______________________________ or view the FMLA poster located in ____________________________________.
PART B – RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE
As explained in Part A, you meet the eligibility requirements for taking FMLA leave and still have FMLA leave available in the applicable 12-month
period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must return the following information to us
by________________________. (If a certification is requested, employers must allow at least 15 calendar days from receipt of this notice; additional
time may be required in some circumstances.) If sufficient information is not provided in a timely manner, your leave may be denied.
Sufficient certification to support your request for FMLA leave. A certification form that sets forth the information necessary to support your
request is enclosed.
Sufficient documentation to establish the required relationship between you and your family member.
Other information needed (such as documentation for military family leave):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
No additional information requested.
If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA leave (only checked blanks apply):
You will be required to use your available paid leave during your FMLA absence. With the exception of the qualifying events outlined in NAC
284.5811 (i.e., workers’ compensation, short or long-term disability benefit), you will be required to exhaust all accumulated compensatory time
and all forms of paid leave time for which you are eligible prior to using leave without pay (NAC 284.5811). This means that you will receive
your paid leave and the leave will also be considered protected FMLA leave and counted against your FMLA leave entitlement. This absence
will involve the use of the type(s) of leave indicated.
Compensatory Time
Annual Leave
Sick Leave
Family Sick Leave
Catastrophic Leave
N/A
You are authorized to begin using FMLA leave codes on your timesheet for any leave used in conjunction with this event. If this event is
later determined not to be eligible for FMLA leave, then the agency will change these codes as appropriate and notify you of the changes.
You should use the following codes:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Notice of Eligibility and Rights & Responsibilities
NPD-62
Page 1 of 2
Rev. 9/18
During FMLA leave the State must maintain your group health insurance on the same basis as if you were not on leave. If you normally pay a
portion of the premiums for your group health insurance [e.g. Self-Funded PPO participant deduction, coverage through a health maintenance
organization (HMO)], you will continue to be responsible for these payments during your FMLA leave. The following apply:
While you are on paid leave, your health insurance will be deducted through normal payroll deductions.
While you are on unpaid leave, you are responsible for making premium payments on the 20th day of each month for insurance coverage
for that calendar month. You have a minimum 30-day grace period in which to make premium payments. If payment is not made timely,
your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health
coverage will lapse, or, 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.
Premium payment will be made to:
The Public Employees’ Benefit Program.
________________________________________ (Other)
Contact ________________________________ at ____________________________________ to make arrangements to continue to
make your share of the premium payments on your health insurance to maintain health benefits while you are on leave.
You have decided to discontinue your insurance coverage during your FMLA leave. You will be restored to coverage upon your return
from leave and will not be required to re-qualify for coverage.
If you normally pay premiums for optional insurance (e.g. dependent health insurance, supplemental life insurance, auto insurance) you will
continue to be responsible for these payments during your FMLA leave. The following apply:
While you are on paid leave, your optional insurance will be deducted through normal payroll deductions.
While you are on unpaid leave, you are responsible for making premium payments to the Public Employees’ Benefit Program or the
applicable vendor (plan administrator) responsible for the coverage. Any questions regarding continuation of health coverage should
be directed to the Public Employees’ Benefit Program at (775) 684-7000.
Due to your status, you are considered a “key employee” as defined in the FMLA. As a “key employee,” restoration to employment may be denied
following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us. We
have
have not
determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous harm to us.
While on leave, you will be required to furnish us with periodic reports of your status and intent to return to work every ________________.
(Indicate interval of periodic reports, as appropriate for the particular leave situation.)
If the circumstances of your leave change, and you are able to return to work earlier than the working day/shift following the last day approved
as FMLA leave, you will be required to notify us at least two workdays prior to the date you intend to report for work.
You have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated as a “rolling” 12-month period measured
backward from the date of any FMLA leave usage.
You have a right under the FMLA for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered servicemember with a serious
injury or illness. This single 12-month period commenced on: _____________________________________.
Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work.
You must be reinstated to the same or equivalent job with the same pay, benefits, and terms and conditions of employment on your return from FMLA-
protective leave. (If your leave extends beyond the end of your FMLA entitlement, you do not have the return rights under FMLA.)
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
could entitle you to FMLA leave; 2) the continuation, recurrence, or onset of a covered servicemember’s serious injury or illness which would entitle
you to FMLA leave; or 3) 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.
If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA leave entitlement, you have the right to have
any compensatory, annual, sick and catastrophic leave run concurrently with your unpaid leave entitlement, provided you meet any applicable
requirements of the leave policy. Applicable conditions related to the substitution of paid leave are referenced or set forth in NAC 284.523 through
284.598. If you do not meet the requirements for taking paid leave, you remain entitled to take unpaid FMLA leave. For a copy of conditions applicable
to sick, annual and other leave usage please check with your agency’s personnel representative.
Once we obtain the information from you as specified above, we will inform you, within 5 business days, whether your leave will be designated
as FMLA leave and count toward your FMLA leave entitlement. If you have any questions, please do not hesitate to contact:
____________________________________________________________ at _____________________________________.
Name
Phone
cc:
Employee's Agency Confidential Medical File
Notice of Eligibility and Rights & Responsibilities
NPD-62
Page 2 of 2
Rev. 9/18
Page of 2