FMLA Request Information Sheet

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					                             Leave of Absence Request Information Sheet
Please notify your Supervisor and/or Department Head of your need to request for leave of absence.
Contact your department’s HR Assistant to obtain all necessary forms that you must complete and to
discuss how your time should be recorded during your absence.

If you are absent due to a health condition, birth or adoption of a child, and/or to take care of a parent,
spouse, or child due to an illness, please contact your HR Assistant for your rights under the Family and
Medical Leave Act (FMLA). The City Policy states that if an employee has FMLA available and the
reason for the leave qualifies under the FMLA, the employee is required take FMLA. FMLA should be
used concurrently with any other leave type (i.e. sick, vacation, or holiday) during the leave of absence

Voluntary and Involuntary Benefits deductions will continue to be taken for Paid Leave of Absences
based on the order of deductions (garnishment is a high priority deduction) out of your bi-weekly check.
If you are not receiving any compensation from the City of Winston-Salem, the following will apply for
your Benefits:

         Employee Only Coverage for Dental
         Your dental coverage will continue to be provided by the City of Winston-Salem if your paid/unpaid leave is
         approved for FMLA. The City will continue to pay the City's cost of the premiums up to twelve (12) weeks or until
         your FMLA entitlement hours have been exhausted.

         Health and Dental Coverage for Dependent/Family
         You will be required to pay premiums for your health and/or family dental coverage while on leave. Your premiums
         will remain the same while you are covered under FMLA. Notify the Payroll Department for payment arrangement;
         otherwise nonpayment could result in cancellation or lapse of coverage.

         Supplemental, Dependent, Short Term Disability, and other Permanent Life Insurance (ex. Colonial and Midland)
         except Unum Provident and CNA Long Term Care)
         The Payroll Department will bill you at the end of each month for past due premiums and payment arrangement will
         need to be made.
         Unum Provident and CNA Long Term Care past due premiums cannot be paid through the Payroll Department. You
         will need to contact these agencies directly.
                 Unum Provident             -   800-635-1049
                 CNA Long Term Care         -   800-266-2904

         NC Retirement/Pension and Valic 457 & Prudential 401(k) Deferred Plans, Flex Spending Accounts, and Charitable
         Deductions will be suspended while on unpaid leave of absence and possibly paid leave of absence, if your paid leave
         of absence does not cover your normal work schedule.

         Garnishments and Child Support
         You need to immediately notify the appropriate agency to make payment arrangements. The City of Winston-Salem
         will not be liable for any circumstances resultant from missed payments during your leave of absence.

You may be eligible to file a Short Term Disability (STD) claim if you elected the group voluntary STD
benefit with Fortis/Assurant. A claim form can be obtained from your Dept HR Assistant, HR Dept, or on
the City’s Employee Center website at
To find out about your claim status call 1-800-733-7879

All FMLA forms (Request for FMLA, Rights and Obligation, and Certification of Health Care Provider)
must be sent to the Human Resources Department).

Rev. 12/09
                               CITY OF WINSTON-SALEM

        This form must be completed and returned to Human Resources at least 30 days before the
desired commencement date of leave if the need for leave is foreseeable or as soon as practicable, if the
need is not foreseeable.

         Final approval of this request is contingent upon Human Resources' confirmation of your
eligibility and receipt of Certification of Health Care Provider Form(s) where required by the City's
FMLA policy. If the requested leave is eventually determined not to be covered by the FMLA, any leave
actually taken will be charged against other types of paid/unpaid or excused/unexcused leave, as
appropriate; including possible termination of your employment.

1.       Name              Employee Number
         Street Address
         City, State, Zip Code
         Home Phone#                 Cell Phone#
         Dept Name               Supervisor/Dept Head
         Scheduled Hours Per Week
I have been employed by City of Winston-Salem at least 12 months and have worked more than 1,250
hours in the past 12 months:    YES         NO

2.       I am requesting for Family and Medical Leave for the following reason:

                          birth of a child or adoption/new foster child or care/bond with newborn (limited to 12 months from birth)
                          (Reasonable documentation such as certificate of birth, court records or adoption paperwork, etc will be
                          care of a ____ spouse, ____ child or ____ parent with a serious health condition (Completed Medical
                          Certification form is required)
                inability to perform my job due to my own serious health condition
                           (Completed Medical Certification form is required)

3.       I request FMLA leave to begin (date)      and end (date)
         Note: Your request must indicate an end date for your request. Leave can be extended with
         adequate documentation from your health care provider beyond end date indicated, but not to
         exceed the 12 weeks per 12 months period entitlement.

4.       If requesting intermittent or reduced hours leave, you must indicate anticipated schedule of leave
         and duration period (ex. 4 hours of intermittent leave 4/29/02 - 5/03/02).

5.       I agree to return to work on the date indicated above. If circumstances change such that I will not
         be able to return to work on that date, I agree to inform my supervisor or dept. assistant of the new
         expected return to work date. Upon my return to work, I must provide a fitness-for-duty
         statement (doctor’s note) from my attending physician.

         ____________________________________                                        ____________________
                  Employee Signature                                                           Date

Rev. 12/09

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