HEALTH CARE PROVIDER CERTIFICATION /Family and Medical ...



|[pic] |Hardship Leave Request |[pic] |

|Employee Section |

|Employee’s name: | |Employee’s OR number: |

|      | |      |

|Agency name: | |Employee’s home/cell phone number: |

|      | |      |

|Please check the type of Hardship Leave you are requesting: |

| |Medical Leave |Requires medical documentation to support your leave |

| |Parental Leave |No medical documentation necessary, but you must meet eligibility criteria |

| |Bereavement Leave |You may receive up to 40 hours of donated leave to be used consecutively |

|Date your continuous leave starts/started: |      |

|Anticipated duration of your leave: |      |

|Please note: If you elected to save your paid leave accruals while on FMLA/OFLA, you will not be eligible to receive hardship donations during the leave period. |

|For more information on hardship leave requirements: |

|Represented employee refer to your collective bargaining agreement: | |

|Management Service, Unrepresented, Executive Service employees refer to the DAS | |

|Policy hardship leave 60.025.01 for medical or parental: | |

|Management Service, Unrepresented, Executive Service employees for donated | |

|bereavement leave refer to DAS Policy 60.000.10 | |

|I request to receive hardship leave from other employees of the Department of Human Services and the Oregon Health Authority (DHS|OHA) |

| |( |I understand that all accrued leave must be exhausted before I am eligible for donations. |

| |( |I understand that my use of donated leave is treated like sick leave and may offset the receipt of any short/long term disability payments. |

| | |      |

|Employee’s signature | |Date signed |

|FMLA/OFLA Contact Information |

|Customer Service Line: |503-945-5646 |

|Email: |fmla-ofla.faxes@dhsoha.state.or.us |

|Fax number: |503-945-5866 |

|Mailing address: |The Office of Human Resources |Shared Services |

| |Attn: OHSE/FMLA |

| |500 Summer St NE, E22 |

| |Salem, OR 97301–1099 |

|Web address: | |

|FMLA/OFLA Staff |

|Assistant: |Laura Tupper | |

|Coordinators: |Matthew Heath |Cindy Peterson |Michelle Garman |

| |Donna Sniezak |Eric Villarreal |Jodie Benson |

|Lead worker: |Michelle Patton | |

|Manager: |Stanton Thomas | |

|Human Resources Section |

|Date continuous leave started: |      |

|First date they entered into leave without pay: |      |

|Approved: |Denied: | |

|Reason for denial: |

|      |

| | |      |

|Human Resources Signature | |Date signed |

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