Request for Leave Form - Milwaukee County, Wisconsin

This "Request for Leave Form" is a part of the paperwork released by the Wisconsin Department of Administration specifically for Wisconsin residents.

The latest fillable version of the document was released on January 1, 2011 and can be downloaded through the link below or found through the department's forms library.

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Request for Leave Form
Please return to
(Completed by the Employee)
Risk Management at
(414) 223-1960 (fax)
within 1-business day.
IT IS YOUR RESPONSIBILITY TO
(414) 278-2921 (office)
FOLLOW YOUR DEPARTMENTAL
CALL-IN PROCESS
To be completed by employee and submitted to Risk Management as soon as possible. Incomplete forms will not be processed.
Employee Name:
Hire Date:
Hours Worked per Week:
Street Address:
Home Phone:
(
)
City:
State:
Zip Code:
Work Phone:
(
)
Supervisor’s Name:
Department:
Work Shift:
1.
Length of Leave: (If your schedule is not Monday through Friday, please attach your work schedule to this form.)
First Day Off: ___________________________
Last Day Off: _______________________________
Return to Work Date: ________________________________________________________________________
If taken intermittently or as a reduced schedule, describe the amount of time needed for this leave and expected
duration for needed leave: ____________________________________________________________________
2.
Type of Leave Requested:
Medical leave for employee’s own serious health condition
(Medical Certification Required)
Family leave for immediate family member with a serious health condition
(Medical Certification Required)
Family leave for bonding ("No medical certification required. However, you are required to submit verification
that you have a new baby in your family. Such verification can consist of a simple statement from you of the
family relationship, your child's birth certificate, a court document, or Milwaukee County insurance records
noting the addition of your child.")
Placement of child for adoption
(Court Documentation Required)
Placement of a child for foster care
(Court Documentation Required)
3.
For leave to care for an immediate family member, please indicate the following:
Full name of the person: _________________________________________________________________
Relationship to employee: ________________________________________________________________
If the person is your child, specify date of birth: ________________________________________________
4.
Please specify what type of time should be used during the state unpaid FMLA benefit, check all that apply:
Sick Allowance (____ hrs.)
Vacation (____ hrs.)
Holiday (____ hrs.)
Personal (____ hrs.)
Unpaid (____ hrs.)
Compensatory Time (____ hrs.)
An employee may choose what earned time off should be used to supplement pay while on state FMLA benefit (the
first two weeks of the leave, or six weeks, if for birth or bonding). After the state benefit has expired, Milwaukee
County will supplement pay by using all available time in the following order: Sick allowance, vacation pay, holiday
pay, personal allowance, and compensatory time. After all time is used, the remaining time will be unpaid. If the
employee has compensatory time available, he/she may select to use it instead of taking time unpaid.
An absence due to a work related injury covered by Injury Pay or Worker’s Compensation will be designated as a FMLA leave
assuming the employee is eligible for FMLA benefits.
You will be notified of the designation of time in writing.
- OVER -
FMLA-02 (Rev. 01/11)
Request for Leave Form
Please return to
(Completed by the Employee)
Risk Management at
(414) 223-1960 (fax)
within 1-business day.
IT IS YOUR RESPONSIBILITY TO
(414) 278-2921 (office)
FOLLOW YOUR DEPARTMENTAL
CALL-IN PROCESS
To be completed by employee and submitted to Risk Management as soon as possible. Incomplete forms will not be processed.
Employee Name:
Hire Date:
Hours Worked per Week:
Street Address:
Home Phone:
(
)
City:
State:
Zip Code:
Work Phone:
(
)
Supervisor’s Name:
Department:
Work Shift:
1.
Length of Leave: (If your schedule is not Monday through Friday, please attach your work schedule to this form.)
First Day Off: ___________________________
Last Day Off: _______________________________
Return to Work Date: ________________________________________________________________________
If taken intermittently or as a reduced schedule, describe the amount of time needed for this leave and expected
duration for needed leave: ____________________________________________________________________
2.
Type of Leave Requested:
Medical leave for employee’s own serious health condition
(Medical Certification Required)
Family leave for immediate family member with a serious health condition
(Medical Certification Required)
Family leave for bonding ("No medical certification required. However, you are required to submit verification
that you have a new baby in your family. Such verification can consist of a simple statement from you of the
family relationship, your child's birth certificate, a court document, or Milwaukee County insurance records
noting the addition of your child.")
Placement of child for adoption
(Court Documentation Required)
Placement of a child for foster care
(Court Documentation Required)
3.
For leave to care for an immediate family member, please indicate the following:
Full name of the person: _________________________________________________________________
Relationship to employee: ________________________________________________________________
If the person is your child, specify date of birth: ________________________________________________
4.
Please specify what type of time should be used during the state unpaid FMLA benefit, check all that apply:
Sick Allowance (____ hrs.)
Vacation (____ hrs.)
Holiday (____ hrs.)
Personal (____ hrs.)
Unpaid (____ hrs.)
Compensatory Time (____ hrs.)
An employee may choose what earned time off should be used to supplement pay while on state FMLA benefit (the
first two weeks of the leave, or six weeks, if for birth or bonding). After the state benefit has expired, Milwaukee
County will supplement pay by using all available time in the following order: Sick allowance, vacation pay, holiday
pay, personal allowance, and compensatory time. After all time is used, the remaining time will be unpaid. If the
employee has compensatory time available, he/she may select to use it instead of taking time unpaid.
An absence due to a work related injury covered by Injury Pay or Worker’s Compensation will be designated as a FMLA leave
assuming the employee is eligible for FMLA benefits.
You will be notified of the designation of time in writing.
- OVER -
FMLA-02 (Rev. 01/11)
Request for Leave Form (continued)
You must provide verbal notice of your need for leave to the designated Risk Management representative at least 30
days (and no more than 45 days) before taking a leave. If you need to take leave because of an unplanned or
emergency situation, you must notify him/her within than one business days after learning of the need for leave.
Failure to give appropriate notice will result in the delay or denial of leave as FMLA leave and could subject
you to corrective action.
You must submit the request for leave form to the designated Risk Management representative within 1-business day.
If the leave is for your own serious health condition, to care for a family member with a serious health condition, or for a
qualifying exigency arising out of the fact that your family member is on active duty or call to active duty status in
support of a contingency operation as a member of the National Guard or Reserves; you must submit sufficient
certification to support your request for FMLA leave. A certification form that sets forth the information necessary to
support your request is enclosed.
Pursuant to the Genetic Information Nondiscrimination Act of 2008 (GINA), Milwaukee County does not request genetic
information from health care providers.
If the leave is for placement of a child, you must submit sufficient documentation to establish the required relationship
between you and your family member.
We will pay your share of the premium payments on your health insurance to maintain health benefits while you are on
unpaid FMLA leave and will recover these payments from you upon your return to work.
Once you have exhausted your state FMLA benefit, you will be required to use your available paid sick, vacation,
holiday, personal time, and overtime during your FMLA leave. This means that you will receive your paid time off, the
time will also be considered protected FMLA leave, and counted against your FMLA leave entitlement.
If you are taking a leave for your own serious health condition, you must submit the fitness for duty certification form
completed by your healthcare provider to the designated Risk Management representative prior to returning to work.
Failure to do so will result in the delay of your return to work, and possibly an unauthorized absence, which may subject
you to corrective action.
If the circumstances of your leave change and you are able to return to work or if leave is taken intermittently
and you are able to return to your regular schedule earlier than the date indicated on the medical certification
of health care provider form, you are required to notify the designated HR representative at least two business
days prior to the date you intend to report for work or to return to a regular schedule.
You have a right under the federal FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated as the
calendar year (January – December) and you have a right under state FMLA for up to two weeks of unpaid leave (six
weeks for bonding leave) - Both federal and state FMLA benefits are run concurrent with each other and also any Civil
Service Rule VIII leave entitlement.
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 the first day of the leave of
absence.
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 an equivalent job with the same pay, benefits, and terms and conditions of
employment on your return from FMLA-protected leave.
(If your leave extends beyond the end of your FMLA
entitlement, you do not have 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 would 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 Milwaukee County for our share of health insurance premiums paid on your
behalf during your FMLA leave.
Once we obtain the information from you as specified above, we will inform you, within five business days, whether your
leave will be designated as FMLA leave and count towards your FMLA leave entitlement.
By signing below, you acknowledge and understand the conditions required of you during a leave of absence.
____________________________________________
___________________________________________
Employee Signature
Date
____________________________________________
___________________________________________
Risk Management Representative
Date Received
FMLA-02 (Rev. 01/11)
2

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