Return From Leave -Video Conference by R3YiEM


									                            PRE & POST LEAVE -VIDEO CONFERENCE CHECKLIST

               Any employee who uses leave for an extended* period of time must schedule a
               conference, through their Office Manager, with Personnel, Benefits and Payroll. The
               conference must occur no later than 10 days before a planned leave* or must be
scheduled within 5 days of return from an unplanned* leave.

Employees from Key West to Sugarloaf must come in person to the human resource office in Key
West. Employees in Marathon and north will participate via videoconferencing.

Definitions for the purpose of scheduling conferences:
    1. Extended leave: Any leave, including sick leave and sick pool, whether paid or unpaid, or
         any type of absence from the job site that is planned or unplanned or lasts for ten working
         days or more. (Examples: sick, vacation, FMLA, personal, WC).
    2. Planned Leave: Any leave about which the employee knows in advance. (Ex.- vacation,
         surgery, FMLA for childcare).
    3. Unplanned leave: Any leave for which the employee did not plan ahead (Ex. - sick leave,
         accidents, WC, FMLA).

Name of employee: ___________________________Job Site: ____________________
Date & Time of conference: ____________________________________
Type of leave: ______________________Number of days out: ________________
First day of leave: __________________ Return date (actual or anticipated): _________
        If due to illness, specify: ___________________________________________

  1. “Fitness to Return to Duty” form (Ex.- WC, surgery) - No, Is not required ____
       Yes, is required____
        If you answered “yes” complete the following:
               Type of illness/injury__________________________________
               Name of Doctor:_____________________________________
               Doctor’s Contact Information: __________________________________

   2. Regular Doctor’s Note Needed (FMLA, Sick, WC)? No__ Yes ____
        If you answered “yes,” what dates must the note cover?
        From ________________ to _____________________

    3. Paperwork needed to complete leave procedure: No, None needed ___ Yes, Forms
        are missing ______
                If you answered “yes”- list the forms that are missing:
          a) __________________________ b) __________________________

          a. Were benefits continued during absence? No____ Yes____
              If they were NOT continued, will they be reinstated now? No___ Yes ____
          b. Is any benefit premium owed by employee? No____ Yes_____.
              IF you answered “Yes”- how much back premium is currently owed?
          c. How will this premium be paid? (check one)
              Paycheck dockage? ______ Lump Sum payment by employee? _____
                       If amount to be paid by dockage of future paychecks:
                      How many checks affected? __________
                      Start date of first deduction? _________
                      Amount of deduction(s) $__________

   5.   PAY ISSUES-
          a. Explanation of Payroll process, if necessary.
                      ___No, not done. ____Yes, explained____
          b. Is there any amount of pay dockage pending? No____ Yes____.
              If yes, what is the amount owed? $_____________________
                               How many checks affected? __________
                               Start date of first deduction- _________
                               Amount of deduction(s) - ___________

Conference conducted by: ___________________________________________

Copy sent to Employee by (circle one) Pony Regular Mail       Hand

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