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					Please check appropriate                     Please print:
company                                      Employee Name: ____________________________
______HMFP                                   Soc. Sec. No.: _______________________________
_______APHMFP                                Department: ________________________________
                                             Mailing Address:_____________________________
_______ CAPHMFP
                                             ___________________________________________.
                                             Home Phone:________________________________
LEAVE OF ABSENCE                             Admin. Director:_____________________________
FORM                                         Admin Director ext. __________________________

SECTION II: Length

Last Day worked: _______________Return to work date: ________________________
(The maximum leave is 1 year)
Reason for Leave of Absence (before making selection, please read the attached FMLA information).
(   ) Medical/Self          (    ) Medical Other         (      ) Medical/Maternity   (   )Adoption
(   ) Personal              (    ) Educational           (      ) Military            (   ) Worker’s Comp.
(   ) Other:


SECTION III:
For all leaves except Personal and Educational leaves: I would like to retain ____________ hours of
vacation time ( up to 80 hours, pro-rated for part-time employees).


SECTION IV: Benefits
Please read “Your Benefits While on Leave” and initial below.

(    ) I do NOT participate in any benefits through HMFP/APHMFP/CAPHMFP.

(   ) I participate in the benefits and I understand I am responsible to pay the employee’s share of the cost.


SECTION V: Reinstatement Guidelines
Please read the following and sign below:

I understand HMFP cannot guarantee my job will be available at the time I return to work.
Efforts will be made to reinstate me in either the same or a comparable position.
Reinstatement following Family & Medical Leaves will be made in accordance with the
Family & Medical Leave Act of 1993.

I understand I must be seen by Employee Health Services (EHS) prior to returning
from Maternity/ Medical Leave and must provide EHS with a written medical clearance
from his/her healthcare provider.

Employee Signature: ___________________________ Date:____________________


Department Chief or designate: ___________________

Date:_________________________


Loaapp.doc 8/08


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                 INFORMATION FOR EMPLOYEES GOING ON LEAVE OF ABSENCE
If you are taking a Leave of Absence, please pay attention to this checklist of things you should
know.

      Read all information in this packet.

      Inform your division’s administrative director of your wish to take a Leave of Absence (LOA).

      Review information sheet on the Family Medical Leave Act (FMLA). If you believe that you qualify under
       the FMLA, please review the enclosed designation form with your division’s administrative director.

      Complete sections I through V on the Leave Of Absence form and request your manager's signature.

      Disability Information

                 If this is a medical or maternity leave AND you are benefits eligible you will need to complete
                 the short-term and or long-term disability application (available upon request.) Disability
                 forms should be mailed directly to the vendor and all completed LOA forms should be returned
                 to your administrative director.

                 IMPORTANT. If your leave is a medical or maternity leave there are certain time
                 limits to file your claim with disability vendors. Please note that short term
                 disability forms should be completed within 14 days of the onset of disability. If you
                 anticipate your leave will extend beyond 90 days, please contact Joanne O’Connell,
                 HR Specialist, (617)-632-9818 to discuss Long-Term Disability benefits.

      Signed, completed LOA forms and, if appropriate, disability forms may be mailed to your administrative
       director or
                             HMFP/APHMFP/CAPHMFP, Professional Staff Benefits Office
                             375 Longwood Avenue
                             Masco Building, 3rd Floor
                             Boston, MA 02215
                             Interoffice: Masco Building, 3rd Floor

      Forms must be received by within 14 days of last day worked.

      Suspend elective payroll deductions, i.e. parking, credit union, etc.

      If you wish to retain any vacation time (if eligible), inform your division’s administrative director prior to
       your leave.

      Call your division’s administrative director manager at least one time per month to keep in touch.

                            BEFORE RETURNING TO WORK FROM AN LOA

      Contact your division’s administrative director 2 WEEKS prior to returning to work, to ensure
       reinstatement.

      If you are returning from a medical or maternity leave, Employee Health Services must clear you.
       Please call 632-0710 to schedule an appointment 2 weeks in advance of your return date. You must
       bring the medical clearance form to your manager on the first day of work.

If you have any questions, please contact Joanne O’Connell in Human Resources at 617-632-9818.




                                                                                                                   2
                       Your Benefits While On Leave Of Absence

The following will describe in general the provisions effecting benefits during an approved leave of
absence. Please note that if your leave is for personal or educational reasons benefits may vary
from those listed below. Please contact Human Resources at (632-9818) for additional details.

Medical and Dental
       If you are currently enrolled, your medical and dental, coverage(s) will continue provided you
       pay your share of the cost (for up to one year). You will be billed for your portion of the
       insurance on a monthly basis. Payment is due upon receipt and failure to pay the balance
       due will result in termination of your coverage. If the leave is for Worker's Compensation,
       the insurance may be covered for up to one year at no cost to you.
Life Insurances and Accidental Death and Dismemberment (AD&D)
       If you are currently enrolled, your life insurance programs through Minnesota Term Life or
       AD&D coverage will continue for 12 months if you are on family or medical leave. Your
       coverage will continue provided you pay your share of the cost. You will be billed for your
       portion of the insurance on a monthly basis. Payment is due upon receipt and failure to pay
       the balance due will result in termination of your coverage. If you currently have a policy
       through HCS, Minnesota Life for GUL/VGUL, spousal and or dependent life insurance you will
       receive a bill directly from the carrier for premiums due. Failure to pay the invoice will result
       in the termination of your coverage.
Short-Term and Long-Term Disability
       Short-term and Long-term disability coverage is extended if you are on medical or maternity
       leave at no cost. All other types of leave, disability coverage will end on the last day of work.
Reimbursement Accounts
       If you participate in a reimbursement account, contributions will stop as soon as the unpaid
       portion of your leave begins. You may still submit claims to your account through March 31st
       of the following calendar year.
Paid Time Off
       Vacation time is regulated at the department level. Please discuss the effect of your leave as
       it relates to your allowed time off with your division’s administrative director.
Pension
       Contributions stop when you are on an unpaid leave and resume when you return to work
       (provided you meet eligibility requirements).
401(k) Contributions
       Contributions stop when you are on an unpaid leave and resume when you return to work
       (provided you meet eligibility requirements).
Credit Unions
       While you are on paid leave direct deposits and/or payments will continue as normal. When
       you go on unpaid leave, you are responsible for contacting the credit union(s) to arrange for
       deposits/payments directly.
Parking/MBTA Pass
       If you have a subsidized parking space or payroll deduction for T Pass, please contact
       Commuter Services to arrange payment or suspension of the deduction or you will be
       responsible for the cost while on leave. You need to contact them again upon return to
       regain your space or restart your T Pass payroll deductions.
Salary Issues
       All discussions on salary should be with your divisional chief.




                                                                                                       3
                    FAMILY AND MEDICAL LEAVE ACT OF 1993

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave
to "eligible" employees for certain family and medical reasons. Employees are eligible if
they have worked for a covered employer for at least one year, and for 1,250 hours over
the previous 12-month and if there are at least 50 employees within 75 miles.

REASONS FOR TAKING LEAVE:

Leave must be granted for any of the following reasons:

      to care for the employee's child after birth, or placement for adoption or foster care;
      to care for the employee's spouse, child, or parent, who has a serious health
       condition; or
      for a serious health condition that makes the employee unable to perform the
       employee's job.

ADVANCE NOTICE AND MEDICAL CERTIFICATION:

The employee may be required to provide advance leave notice and medical certification.
Taking of leave may be denied if requirements are not met.

      The employee ordinarily must provide 30 days advance notice when the leave is
       "foreseeable."
      An employer may require medical certification to support a request for leave because
       of a serious health condition, and may require second or third opinions (at the
       employer's expense) and a fitness for duty report to return to work.

JOB BENEFITS:

      For the duration of FMLA leave, the employer must maintain the employee's health
       coverage under any "group health plan."
      Upon return from FMLA leave, most employees must be restored to their original or
       equivalent positions with equivalent pay, benefits, and other employment terms.
      The use of FMLA leave cannot result in the loss of any employment benefit that
       accrued prior to the start of an employee's leave.

FMLA makes it unlawful for any employer to:
   Interfere with, restrain, or deny the exercise of any right provided under FMLA.
   Discharge or discriminate against any person for opposing any practice made
     unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.

FOR MORE INFORMATION:

If you have questions or concerns related to FMLA, please call Joanne O’Connell in Human
Resources at (617)-632-9818.




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             General Contact Information While On LOA



Service Contact                              Phone Number

Credit Unions
                    ALPHA                        617-632-8164

                    MAFCU                        617- 732-4185


Employee Occupational Health Services

Beth Israel Deaconess Medical Center             617-632-0710
Nashoba                                          978-784-9633
St. Vincent’s Hospital                           508-363-6036
Landmark                                         401-769-4100
                                                 ext.2078
BIDNeedham                                       781-453-3032

HMFP/APHMFP/CAPHMFP Human Resources, Benefits    617-632-9818

Parking/Commuter Services (BIDMC)                617-667-3035




                                                                 5
                HMFP/APHMFP/CAPHMFP Human Resources
                         375 Longwood Ave
                       Masco Building, 3rd Floor
                         Boston, MA 02215



                 RETURN TO WORK FORM
   TO BE COMPLETED ON FIRST DAY OF EMPLOYEE'S RETURN TO WORK


EMPLOYEE NAME: ___________________________________________________

SSN: ______________________

FIRST DAY EMPLOYEE RETURNED TO WORK: _____/_____/_____

DEPARTMENT:______________________________________________________

WORK TELEPHONE NUMBER: _____________________________



________________________________________   ____________________
Administrator’s Signature                  Date

        Please fax completed form to HMFP/APHMFP/CAPHMFP’s
                    HR Department at 617-632-9752.




PLEASE NOTE THAT ANY ADJUSTMENTS TO THE FIRST PAYROLL
    SHOULD BE COMMUNICATED TO PAYROLL VIA YOUR
          HMFP/APHMFP/CAPHMFP TIMESHEET.




                                                                     6
Leaves             of    Absence
HMFP/APHMFP/CAPHMFP recognizes that medical, personal and family needs sometimes require an
extended absence from work. To accommodate these needs, HMFP/APHMFP/CAPHMFP provides
leaves of absence for a variety of reasons. Eligibility, your right to continue benefits, maximum duration
of leave, and return-to-work provisions vary with each type of leave. A leave of absence may include
paid, unpaid or a combination of paid and unpaid time depending upon your department’s
vacation/sick/holiday program.

You are responsible for ensuring that your supervisor or manager is kept apprised of any absence from
work, whether paid or unpaid. Generally, you will be expected to ask your supervisor or manager for time
off for periods of less than 14 days. Although the reason for this shorter-term absence may qualify under
some of the leaves described below, no leave of absence forms need to be filled out.

For leaves anticipated to last more than 14 days, a leave of absence form must be obtained, completed,
approved and filed with HR Department. You should give as much advance notice as possible, usually at
least two weeks.

The following is a brief description of the specific leaves of absence:

Family and Medical Leaves (FMLA): A leave (12 week maximum) taken by eligible employees for one
of the following reasons: the birth of a child and in order to care for that child; the placement of a child for
adoption or foster care; the care of a spouse or gay/lesbian partner, child, parent with a serious health
condition (as defined by law); or the serious health condition of the employee that makes him/her unable
to perform the essential functions of his/her position. Documentation from a physician or other health
care provider may be required in order to qualify for this leave. In order to be eligible for FMLA leave, you
must have been employed with HMFP for 12 months and must have worked at least 1250 hours during
the twelve-month period immediately before the leave commenced. If you return to work at or before the
conclusion of 12 weeks FMLA leave, you will be returned to your same job or a job with equivalent
status, pay benefits and other employment terms. If your leave is longer than 12 weeks and your position
is filled, you may apply for other positions for which you are qualified. You will be given preference in re-
hire for any job you are qualified to perform, provided you were in good standing prior to taking your
leave.

Maternity and Adoption: An eight week leave will be granted to regular full-time or benefits eligible part-
time employees with at least three months of continuous employment for the purpose of giving birth or
adopting a child. If you also are eligible for FMLA leave, such leave will run concurrently. Documentation
from a physician or other health care provider may be required to qualify for this leave. If you return to
work at or before the conclusion of your approved leave, you will be returned to your same job or a job
with equivalent status, pay, benefits and other employment terms. If your leave is longer than eight
weeks and your position is filled, you may apply for other positions for which you are qualified. You will

                                                                                                              7
be given preference in re-hire for any job you are qualified to perform, provided you were in good
standing prior to taking your leave.

“Small Necessities” Leave: Time away from work (up to 24 hours during a 12 month period) for
participation in: educational activities of a son or daughter, such as parent-teacher conferences;
accompanying a son or daughter to routine medical/dental visits; accompanying an elderly relative of the
employee (60 years or older) to routine medical/dental visits or other professional services related to
elder care. You must complete twelve months of continuous employment and have worked a minimum of
1250 hours in order to be eligible for this leave. At least seven days notice, or, if unforeseeable, as much
notice as possible is required for this leave.

Workers’ Compensation: A leave taken due to a work-related illness or injury. If the illness or injury is a
serious health condition, the leave also may be an FMLA leave and will run concurrently. If you return to
work at or before the conclusion of 12 weeks of leave, you will be returned to your same job or a job with
equivalent status, pay benefits and other employment terms. If you return from an approved leave of
longer duration, you will be returned to your same or similar position, when possible. If your leave is
longer than 12 weeks and your position is filled, you may apply for other positions for which you are
qualified. You will be given preference in re-hire for any job you are qualified to perform.

Personal or Educational: A leave (12 month maximum) taken for personal reasons or a leave taken to
pursue educational advancement in an area or field that is work-related. To be eligible for this leave,
twelve months of continuous employment is required. Under this leave, there is no job reinstatement
guarantee. Your position may be held open or filled at any time, depending on your manager’s discretion.

Military: A leave taken by a member of the armed forces of the United States or the Commonwealth of
Massachusetts to attend assigned military service. If you are required to serve an annual tour of duty as
a member of a reserve component, then HMFP will pay any difference between your military pay and
your regular pay up to a maximum of 17 days within the calendar year. During periods of crisis, all
employees other than temporary employees called to active duty or who volunteer for active duty are
eligible for military leaves of absence. HMFP/APHMFP/CAPHMFP may issue special pay and benefit
provisions to correspond to the circumstances at the time.

Detailed information on all leaves of absence, and the leave of absence process, is available through
Human Resources, 375 Longwood Ave, Masco Bldg., 3rd Floor, or 617-632-9818. For information on the
effect of your benefits with each type of leave, please refer to the leave of absence packet.




                                    Y:\Human Resources\Joanne\LOA forms\loa email forms\LOA Application Packet.DOC


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