S E C T I O N 3 0 0 : C O M P E N S A T I O N

Section 400.600: Family and Medical Leave Act

EXHIBIT B

Response to Employee Request for Family or Medical Leave

(Family and Medical Leave Act of 1993)

DATE: _________________________

TO: ___________________________________________________________

(Employee’s name)

FROM: ________________________________________________________

(Name of appropriate employer representative)

SUBJECT: Request for Family/Medical Leave

On _______________ you notified us of your need to take family/medical leave due to:

(date)

G the birth of a child, or the placement of a child for adoption or foster care; or

G a serious health condition that makes you unable to perform the essential functions of your job: or

G a serious health condition affecting your G spouse, G child, G parent, for which you are needed to provide care.

You notified us that you need this leave beginning on _______________ and that you expect leave to continue until on or about _______________.

Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period for the reasons listed above. Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work, and 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 leave. 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; or (2) 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.

This is to inform you that: (check appropriate boxes: explain where indicated)

1. You are G eligible G not eligible for leave under the FMLA.

2. The requested leave G will G will not be counted against your annual FMLA leave entitlement.

3. You G will G will not be required to furnish medical certification of a serious health condition. If required, you must furnish certification by _______________ (insert date) (must be at least 15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted.

4. You may elect to substitute accrued paid leave for unpaid FMLA leave. We G will G will not require that you substitute accrued paid leave for unpaid FMLA leave. If paid leave will be used the following conditions will apply: (Explain)

___________________________________________________________________________

5.a. If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of FMLA leave. Arrangements for payment have been discussed with you and it is agreed that you will make premium payments as follows:

___________________________________________________________________________

b. You have a minimum 30-day grace period in which to make premium payments. If payment has not been made timely, your group health insurance may be canceled, 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.

c. We G will G will not pay your share of the premiums for your health, dental, and life insurance while you are on leave.

6. You G will G will not be required to provide medical certification prior to being restored to employment. If such certification is required but not received, your return to work may be delayed until such certification is provided.

7.a. You G are G are not a “key employee” as described in FMLA Policy 400.630, #8. If you are 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.

b. We G have G have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to us. (Explain a. and/or b. below.)

___________________________________________________________________________

8. You G will G will not be required to furnish us with periodic reports of your status and intent to return to work every 30 days while on FMLA leave.

9. You G will G will not be required to furnish recertification every 30 days relating to a serious health condition. (Explain below, if necessary.)

___________________________________________________________________________

_____________________________________________

(Employer Representative Signature)

_______________________

(Date)

FMLA Exhibit B