County Administration Human Resources

Employee Request for FMLA

Family Medical Leave Act

FMLA REQUEST PROCESS

Once this form has been submitted, you will receive a WH-381 Notice of Eligibility & Rights and Responsibilities form, which will indicate whether or not you are eligible for FMLA Leave.  Being designated as eligible is not an approval of leave.  Approval will only be granted on a WH-382 Designation Notice.

If eligible, the employee will also receive a WH-380 Certification of Health Care Provider form to provide to their health care provider.  This form must be completed by the treating physician and returned to County Administration/HR within 15 days of the receipt of the form.  

The Employee and the Employee's Supervisor will receive form WH-382 Designation Notice within 5 days of receipt of the completed WH-380 Certification of Health Care Provider form.  This form provides the approval or denial of the FMLA Request.  Contact countyadminhr@mcleancountyil.gov or 309-888-5110 with any questions.  

SERIOUS HEALTH CONDITION

In order for FMLA to apply to the absence, the reason must meet the definition of a Serious health condition.  

The most common serious health conditions that qualify for FMLA leave are:

• conditions requiring an overnight stay in a hospital or other medical care facility;
• conditions that incapacitate you or your family member (for example, unable to work or attend school) for more than three consecutive days and have ongoing medical treatment (either multiple appointments with a health care provider, or a single appointment and follow-up care such as prescription medication);
• chronic conditions that cause occasional periods when you or your family member are incapacitated and require treatment by a health care provider at least twice a year; and
• pregnancy (including prenatal medical appointments, incapacity due to morning sickness, and medically required bed rest).

Department of Labor FMLA FAQs 

REASONS FOR LEAVE

Pregnancy/Birth:  The birth and bonding of the employee's child and the recovery from pregnancy.  

Bonding:  To bond with your newborn within the 1st year of their birth, or for the placement of and bonding with a child for adoption or foster care.  

Family Member:  To care for an immediate family member (spouse, child, or parent - but not a parent "in-law") with a qualifying serious health condition

Self:  To take medical leave when the employee is unable to work becasue of a serious health condition

Active Duty - Military:  For qualifying exigencies arising out of the fact that the employee's spouse, son daughter, or parent is on covered active duty or call to covered active duty status as a member of the National Guard, Reserves, or Regular Armed Forces.

Leave to care for or bond with a newborn child or for a newly placed adopted or foster child may only be taken intermittently with the employer’s approval and must conclude within 12 months after the birth or placement.

Leave dates are required in order to submit a request, even if they are only estimated dates.  If you are unsure, please use an estimated date.

LEAVE START DATE:  the first date you anticipate being out of the office for this leave.  If you are unsure of this date, enter an estimate.  

LEAVE END DATE:  the date you expect to return to work at your normal schedule.  If you are unsure of this date, enter an estimate.  This date can be updated based on feedback from the healthcare provider completing the appropriate certification. 

If your leave will extend beyond the 12 weeks of FMLA entitlement granted in a 12 month period, and you will have exhausted all accrued paid time off, then a request for a Continuance of Unpaid Leave must be submitted to your Department Head as soon as possible.  This request must be approved by the department head, the County Administrator, and the appropriate committee of the County Board.  Read more about this policy in Chapter 108-39 Leaves of absence without pay.

If you believe you will require Short Term Disability (Tier 1,Tier 2, SLEP 1, SLEP 2) please contact IMRF at 1-800-275-4673 as soon as possible. 

LEAVE TYPE

Continuous Leave:  Continuous FMLA leave is FMLA leave that is taken and not broken up by periods of work. Continuous FMLA leave is typically when an employee is absent for three consecutive business days or longer and has been treated by a doctor. For example, after a knee surgery and employee's physician instructs the employee to rest and not work for 6 weeks, those 6 weeks are considered continuous FMLA leave.

Intermittent Leave:  When it is medically necessary, employees may take FMLA leave intermittently, taking leave in separate blocks of time for a single qualifying reason or on a reduced leave schedule, reducing the employee’s usual weekly or daily work schedule. When leave is needed for planned medical treatment, the employee must make a reasonable effort to schedule treatment so as not to unduly disrupt departmental operations.  Leave taken must coincide with the expected frequency reported on the Certification of Healthcare Provider form.  A significant change in intermittent leave frequency may require further certification. 

Only intermittent leave that is actually taken is counted against the 12-week time period allotted per 12 month period.

When using intermittent leave, employees must follow the established department procedures for notification of time off.  

Combination Leave:  Combination leave is when the employee will have a period of continuous leave either proceeded or followed by a period of intermittent leave for the same serious medical condition.  An example is an employee who is taking FMLA to care for a child having surgery who takes continuous leave for three weeks while their child is on full bed rest, then half days when their spouse is available to care for the child the  remaining time.

By submitting this form, I certify that I was not and will not be employed and working elsewhere during the period covered by this request for leave for my own illness or serious health condition.  I also certify that I have read and undertand the information on this form. I certify that my absence is because of the indicated reason and that all of the information on this form is true and correct.  I understand that I must continue to follow all time off request policies required by my department when utilizing approved intermittent leave and any approval is only for the serious health condition or event that is indicated on this form.