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					                                                                 GE Aircraft Engines


Memo
 Date:     April 17, 2011
 To:       FMLA Applicant
 From:     Alice Guillott
 RE:       FMLA Application Instructions



 In order not to delay the processing of your application, please follow the instructions below:

          Completely fill out the Family Leave Request Form (such as, Reason for Leave, Dates of
           Leave) sign and have it signed by your immediate manager.

          Complete the GE Health Advantage Authorization For Release of Medical Information ONLY
           IF YOU HAVE A PERSONAL ILLNESS THAT IS BEING HANDLED BY THE DISABILITY
           CENTER.

          Have your physician fully complete the Medical Certification Form for you or your family
           member that is being treated as indicated below:

           If leave is for your personal illness:

           The physician should complete Items 1 thru 7c, sign and date the form.

           If leave is to care for a qualified family member:

           Complete items 1 thru 6c and 8a thru 8c for the qualified family member, indicate the care that
           you will provide the family member and sign at the bottom of the form.

          READ THE FACT SHEET SO THAT YOU KNOW YOUR RIGHTS.



 RETURN ALL THE COMPLETED FORMS AFTER YOU AND YOUR DOCTOR HAVE
 COMPLETED THEM TO ALICE GUILLOTT, BUILDING 501, Mail Drop J110, FIRST FLOOR,
 COLUMN A17, 243-7509; OR TERESA LACEFIELD, FIRST FLOOR, COLUMN B12. 243-4864,
 PRESS 5 TO LEAVE A MESSAGE.
                      GE Aircraft Engines
                      Family or Medical Leave Request
                                                         Please Print or Type
Badge No./Pay No.                 Name                                  Service                Exempt   Hourly      Location
                                                                        Date
                                                                                            Non-Exempt
Social Security No.               Job Title                                            Operation/Department         Component No.

Home Address - No. Street                                                   City                        State       Zip Code

I request a leave covered under Family Medical Leave Act (FMLA) for the following:

    Birth, Placement, Adoption of a Child - May only be taken for continuous periods.
      (Proof of Birth, placement or adoption maybe required)
    Care for a Seriously Ill Family Member*                                        Name
                                                                           Relationship
   Employee’s Own Serious Personal Illness*

   Intermittent **      Reduced      Continuous                           ** Intermittent leaves may be reviewed periodically

*Medical Certification required
                 Dates Leave Requested from:                                              to:
Prior FMLA Leaves:

I understand that at the end of a leave taken pursuant to the Family Medical Leave Act (for birth, adoption or placement of a child,
or to care for a seriously ill family member or for my own illness), I will be returned to my current position or one of equal pay,
seniority, and benefits, Provided I have not exhausted my entitlement under FMLA. My right to return to my job will be in
accordance with the provisions of any applicable collective bargaining agreement, to the extent they are consistent with the FMLA.
If I can not return on the designated date, I understand that I must, in advance, in writing, request an extension. Failure to report
back to work or notify management may result in my employment status being changed to resignation. I further understand that
any applicable personnel actions (e.g. layoff, scheduled salary action, etc.) will proceed upon my return. I also understand that any
false answers or statements made knowingly by me on this request or in connection with an extension of this request, will be
sufficient ground for disciplinary action up to and including discharge.

Employee Signature                                       Date                   Phone (home/work)               Mail Drop

Reviewed by
Immediate Manager/Supervisor Signature                   Date                   Phone (work)                    Fax Number

Immediate Manager/PRINT NAME

                                                Request is      Approved          Denied
              Dates leave approved from:                                             to:
FMLA Coordinator Signature                               Date                   Phone (work)                    Fax Number




           Note:
                     Employee is required to notify manager prior to using FMLA time
                     If approved leave is taken as „intermittent‟ or „reduced‟ time, mark “FA” on the employee‟s
                      time card.
                     Employee is removed from payroll via HR Oracle for continuous absences of 10 or more
                      workdays.
                     Mail Form to J110 or Fax to 243-4038                                 GT4-1 (03/04)
GE Aircraft Engines

                                                             General Electric Company
                                                             Medical Department
                                                             One Neumann Way, Mail Drop C14
                                                             Cincinnati, OH 45215-1988




Dear Doctor:

Your patient or a family member has applied for leave under the Family & Medical Leave
Act. Please read and fully complete the enclosed form as follows:
       If leave is for our employee’s personal health condition:

       Complete Items 1 thru 7c of the form, sign and date the form.

       If leave is for the care of the patient by our employee:

       Complete items 1 thru 6c and 8a thru 8c for your patient, sign and date the
       form.

If a question is not applicable to your patient, please respond with N/A.

Thank you for your cooperation.



GEAE Medical Department
     MEDICAL CERTIFICATION OF PHYSICIAN OR PRACTITIONER FOR
               QUALIFIED FAMILY OR MEDICAL LEAVE

                               (Family and Medical Leave Act of 1993)

1.      Employee’s Name:

2.      Patient’s Name (If different from employee):

3.      Definition of Serious Health Condition, describes what is meant by a “serious
        health condition” under the Family and Medical Leave Act. Does the patient’s
        condition1 qualify under any of the categories described? If so, please check the
        applicable category.
“Serious Health Condition” means an illness, injury, impairment, or physical or mental
condition that involves one of the following:


A. Hospital Care     □
                    Inpatient care (i.e., an overnight stay) in a hospital, hospice, or
   residential medical care facility, including any period of incapacity2 or subsequent
   treatment in connection with or consequent to such inpatient care.
B. .Absence Plus Treatment         □
                                   A period of incapacity of more than three consecutive
   calendar days (including any subsequent treatment or period of incapacity relating to
   the same condition), that also involves:

        a) Treatment3 two or more times by a health care provider, by a nurse or physician’s assistant
             under direct supervision of a health care provider, or by a provider of health care services
             (e.g., physical therapist) under orders of, or on referral by, a health care provider; or
        b)   Treatment by a health care provider on at least one occasion which results in a regimen of
             continuing treatment under the supervision of the healthcare provider.

C. Pregnancy □ Any period of incapacity due to pregnancy, or for prenatal care.




1
 Here and elsewhere on this form, the information sought relates only to the condition for which the
employee is taking FMLA leave.
2
 “Incapacity,” for purposes of FMLA, is defined to mean inability to work, attend school or perform other
regular daily activities due to serious health condition, treatment therefore, or recovery there from.
3
 Treatment includes examinations to determine if a serious health condition exists and evaluations of the
condition. Treatment does not include routine physical examinations, eye examinations, or dental
examinations.
      D. Chronic Conditions Requiring Treatments □ A chronic condition which:
              a)   □ Requires periodic visits for treatment by a health care provider, or by a nurse or
                   physician’s assistant under direct supervision of a health care provider;

              b)   □ Continues over an extended period of time (including recurring episodes of single
                   underlying condition); and

              c)   □ May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes,
                   epilepsy, etc.).

              d) Permanent/Long-Term Conditions Requiring Supervision          □
                                                                               A period of incapacity which is
                 permanent or long-term due to a condition for which treatment may not be effective. The
                 employee or family member must be under continuing supervision of, but need not be
                 receiving active treatment by, a health care provider. Examples include Alzheimer’s, a severe
                 stroke, or the terminal stages of a disease.

      F.   Multiple Treatments (Non-Chronic Conditions) □ Any period of absence to receive
           multiple treatments (including any period of recovery there from) by a health care
           provider or by a provider of health care services under orders of, or on referral by, a
           health care provider, either for restorative surgery after an accident or other injury, or
           for a condition that would likely result in a period of incapacity of more than three
           consecutive calendar days in the absence of medical intervention or treatment, such as
           cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney
           disease (dialysis).


4.         Describe the medical facts that support your certification, including a brief statement
           as to how the medical facts meet the criteria of one of these categories:




5a.        State the approximate date the condition commenced, and the probable duration of
           the condition, and also the probable duration of the patient’s present incapacity if
           different:


5b.        Will it be necessary for the employee to take work only intermittently or to work on
           a less than full schedule as a result of the condition (including for treatment
           described in item 6 below)? If yes, give the probable duration:


5c.        If the current condition is a chronic condition (condition “D”) or pregnancy, state
           whether the patient is presently incapacitated and the likely duration and frequency of
           episodes of incapacity.
6a.       If additional treatments will be required for the condition, provide an estimate of the
          probable number of such treatments:



          If the patient will be absent from work or other daily activities because of treatment
          on an intermittent or part-time basis, also provide an estimate of the probable number
          and interval between such treatments, actual or estimated dates of treatment if known,
          and period required for recover, if any:




6b.       If any of these treatments will be provided by another provider of health services (e.g.
          physical therapist), please state the nature of the treatments




6c.       If a regimen4 of continuing treatment by the patient is required under your
          supervision, provide a general description of such regimen (e.g., prescription drugs,
          physical therapy requiring special equipment):




7a.       If a medical leave is required for the employee’s absence from work because of the
          employee’s own condition (including absences due to pregnancy or a chronic
          condition), is the employee unable to perform work of any kind?



7b.       If able to perform some work, is the employee unable to perform any one or more of
          the essential functions of the employee’s job (the employee or the employer should
          supply you with information about the essential job functions)?



          If yes, please list the essential functions the employer is unable to perform:




7c.       If neither 7a. nor 7b. applies, is it necessary for the employee to be absent from work
          for treatment?


      4
        A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an
      antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of
      treatment does not include the taking over-the-counter medications such as aspirin, antihistamines, or
      salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit
      to a health care provider
8a.      If leave is required to care for a family member of the employee with a serious health
         condition, does the patient require assistance for basic medical or personal needs or
         safety, or for transportation?



8b.      If no, would the employee’s presence be to provide psychological comfort be
         beneficial to the patient or assist in the patient’s recovery?


8c.      If the patient will need care only intermittently or on a part-time basis, please indicate
         the probable duration of this need:




           Signature of Health Care Provider                          Date


                     Type of Practice                                 Telephone Number

         _________________________________________________________
           Street Address

         _________________________________________________________
           City & State

      To be completed by the employee needing family leave to care for a family member:

      State the care you will provide and an estimate of the period during which care will be
      provided, including a schedule if leave is to be taken intermittently or if it will be
      necessary for you to work less than a full schedule




                     Employee’s Signature                                    Date
COMPLETION OF THIS FORM IS STRICTLY VOLUNTARY-IT IS
NOT A CONDITION OF APPROVAL OF YOUR FMLA.


AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION


Patient Name (please print) _________________________________________________

Birthdate ___________________Social Security Number _________________________

I, the undersigned, hereby authorize _________________________________to provide
clarification regarding my medical certification for my FMLA leave to the General
Electric Company Physician or his designate.

                      J.J. Zerbe, M.D., Medical Director
                      GE Aircraft Engines Medical Department
                      One Neumann Way, Mail Drop C14
                      Cincinnati, Ohio 45215

This statement must be signed and dated, and may be revoked at any time except to the
extent action has been taken prior to revocation. This consent will expire in sixty (60)
days after the date below, or sooner by my choice, in which case this consent will expire
on __________________. I hereby state that I have read and fully understand the above
statements as they apply to me. I hereby consent to the disclosure of the treatment
records for the purpose and extent stated above.

Patient Signature _____________________________ Date ______________________


Address _______________________________________Birthdate __________________


Witness _______________________________________Medical Record # ___________


This information will be safeguarded and used in accordance with commonly accepted
limitations related to doctor/patient communications. It is not the policy of the General
Electric Company to pay for information individuals request from their doctor.



_______________________________             _____________________________________
           Date                                          John J. Zerbe, MD
                                                         Medical Director
                     AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
            (ONLY REQUIRED IF ABSENCE IS RELATED TO A SHORT TERM DISBILITY CLAIM)

        TO: GE DISABILITY CENTER
        Indicate applicable GE Health Plan: HCP:____GEMB: ____ Other (insert name): _______________

      Name of individual authorizing use or disclosure: _______________ _______________________________________
        Subscriber ID/SSN#: ______________ _______________________________________________________________
        Address: ________________________ ______________________________________________________________
        Telephone #:    (____)______-_________Fax # (____)______-________
        Cell Phone #(____)______-___________

        I authorize the use or disclosure of the above-named individual’s information as described below. Check all
        that apply:
         Any and all records including mental health, HIV/AIDS, genetic testing and/or substance abuse
             records.
             (Cross out any item you do not authorize to be released)
         Records regarding treatment for the following condition or injury
             _____________________________________
             __________________________________ on or about
        ______________________________________________
         Records covering the period of time _____________________ to
             _____________________________________
         Other (Please specify and include
             dates______________________________________________________________________________
             ______________________________________________________

        This information may be disclosed to, and used by, the following individuals or organizations:
        Name: GENERAL ELECTRIC-FMLA ADMINISTRATOR
        Address: ____________________________________________________________

        Name: _______________________________________________________________________

        Address: ________________________________________________________________

        Please indicate the purpose(s) for this release of information. Check all that apply:
        □ Enrollment information         □ Benefit or Coverage information         □ All claims information
        □ All services from a specific health care provider (List provider’s name):
        _________________________________
        □ For the following purposes: FMLA SUBSTANTIATION

        This authorization is voluntary.I may revoke this authorization at any time by notifying in writing the
        company/individual listed above from providing the information identified in this authorization, but if I do revoke
        this authorization, it won’t have any affect on any actions taken before my revocation was received.

           I would like this authorization to expire on (enter date): _____/_____/_____
            (If no expiration date is provided, this authorization will expire twelve (12) months from the date of
        receipt)
         Payment, enrollment or eligibility for benefits for my health care will not be affected if I do not sign
            this form.
         Information disclosed as a result of this authorization may no longer be protected by federal privacy
            laws and may be disclosed by the company or individual receiving the authorization.
         I should retain a copy of this authorization form.


        Signed:____________________________
        Print Name:_________________Date:________
        Signature of individual, parent on behalf of minor or legal representative

If signed by a legal representative, relationship to individual: ________________________________
Please provide representative documentation, i.e. Power of Attorney, Health Care Surrogate or Guardianship papers
           WHAT YOU NEED TO KNOW ABOUT TAKING FMLA LEAVE

Under the Family and Medical Leave Act, you have the following rights and
responsibilities:

12-Week Entitlement
      You are entitled to 12 weeks of leave in a 12-month period. This leave that you
      are requesting will count against this entitlement. GEAE uses a rolling year, from
      the first day of FMLA leave, for determining how much leave you have
      remaining.

Medical Certification
      GEAE requires medical certification for all FMLA leave requests involving the
      employee or a qualified family member’s Serious Health Condition.

       This certification will be kept with your secured file to ensure confidentiality.

Substitution of Paid Leave
       Where GEAE’s current leave practices overlap with the provisions of the FMLA,
       the time off, up to 12 weeks in a rolling 12-month period, will be used to satisfy
       FMLA requirements.

           Personal Illness Leave:
            o Vacation:        You may request, but are not required, to use any
                               remaining paid vacation days before taking unpaid FMLA
                               leave. The vacation days will not extend your 12-week
                               entitlement period.
            o Sick Days:       You must use any remaining personal illness days before
                               taking unpaid leave under the FMLA. Personal illness
                               leave for less than 10 days will not be counted toward your
                               12-week FMLA entitlement unless you request that it be
                               counted as FMLA leave and you can provide medical
                               certification which shows that your absence was due to a
                               Serious Health Condition. If you are out for more than 10
                               days, all of the time you are absent will be considered
                               FMLA leave unless you present evidence to show that your
                               absence was not due to a Serious Health Condition.

             Leave to Care for a Qualified Family Member:
            o Vacation:     You may request, but are not required, to use any
                            remaining paid vacation days before taking unpaid FMLA
                            leave. The vacation days will not extend your 12-week
                            entitlement.
            o Personal Business:
                            If you are a salaried employee, you may, with your
                            manager’s approval, use your remaining personal
                            business days before going on unpaid FMLA leave. If you
                            are an hourly employee, you must use any remaining
                            personal days before going on unpaid FMLA leave. The
                            paid personal business days will not extend your 12-week
                            entitlement.
Payments for Benefits Continuation
     While on FMLA leave, you will receive a monthly invoice from the Benefits
     Continuation Center.
      If you are on a leave for personal illness, your medical and dental benefits will
         continue at no cost to you. Your remaining benefits will continue, provided
         you make your monthly contributions in advance.
      If you are on leave to care for a Qualified Family Member, you must make
         monthly contributions in advance to continue your benefit coverage.

When You Return
     You are entitled to be returned to your own job, or, if unavailable, a similar job
     offering equal pay, benefits and working conditions, unless otherwise provided
     under a collective bargaining agreement. However, you have no greater right to
     reinstatement or other benefits than if you had been continuously employed
     during the FMLA leave period. For example, if your job is impacted by a
     reduction-in-force, you will not be entitled to reinstatement. If the case of FMLA
     leave is for personal illness, you may be required to present certification from
     your health care provider that you are able to resume work.

If you have further questions about your rights under the Family Medical Leave Act
of 1993, you should contact your Manager or Human Resources Representative.




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