PA Office of Administration Letter



April 28, 2010BRENDA EMPLOYEE123 MAIN STREETANYTOWN, USA 12345Personnel Number: 987654Dear Ms. Employee:Please review the information on the enclosed Designation Notice as it applies to an absence that qualifies as leave under the Family and Medical Leave Act (FMLA). Follow the instructions within the Notice. If the Notice includes a due date and you do not act by the date on the Notice as a result of this letter, you should be aware that you may lose some or all of rights and benefits explained in the Notice to Employee that you were provided with my letter dated April 15, 2010. If you should have any questions, please contact the SPF Absence Coordinator named within the form. PA Relay Service for the deaf or hard of hearing is available at 1.800.682.8706.Sincerely,Mary AnalystSPF Absence CoordinatorFor:John SmithDirectorCommonwealth AgencyEnclosures:Designation Noticecc:Bureau DirectorSupervisor (including copy of SPF Absence Checklist for Supervisors)Time AdvisorTimekeeperSPF CoordinatorOfficial Personnel FolderThis action does not indicate and should not be interpreted to indicate that you are regarded by the Commonwealth as having a disability as defined by the ADA. Sample Designation NoticeFamily & Medical Leave Act Commonwealth of PennsylvaniaEmployee Information:Employee NamePersonnel NumberAgency FORMTEXT Brenda Employee FORMTEXT 987654 FORMTEXT Commonwealth AgencyApproval Information: Absence Begin DateAbsence End DateHours To Be Used During Absence Period FORMTEXT 04/12/10 FORMTEXT 06/30/10 FORMTEXT 435.00Date of Information ReceivedDate Clarifications Received (if any) FORMTEXT 04/27/10 FORMTEXT ?????Your request for leave under the FMLA and Sick, Parental and Family care (SPF), Military Exigency, or Military Caregiver Absence and any supporting documentation that you have provided for the absence beginning on the above date for the reason identified below has been reviewed: FORMCHECKBOX The FORMDROPDOWN FORMCHECKBOX Your own serious health condition. FORMCHECKBOX Because you are needed to care for FORMDROPDOWN due to his/her serious health condition. FORMCHECKBOX Because of a qualifying exigency arising out of the fact that your FORMDROPDOWN is on active duty or call to active duty status in support of a contingency operation as a member of the National Guard or Reserves. FORMCHECKBOX Because you are needed to care for FORMDROPDOWN with a serious injury or illness.The most recent information you provided was provided on the date identified above, and: FORMCHECKBOX Your absence is approved and all leave taken for this reason through FORMTEXT June 30, 2010 will be designated as FMLA leave, provided you submit recertification, if indicated below. FORMCHECKBOX You are required to provide recertification within 15 days following your first absence that occurs after FORMTEXT ?????. FORMCHECKBOX If you have an absence due to this reason after FORMTEXT June 30, 2010 (the duration certified by the health care provider), you will be required to provide a request to extend the absence and new certification. FORMCHECKBOX If you have an absence due to this reason after FORMTEXT ????? (the end of your eligibility year), your eligibility will be re-measured and you will be required to provide new certification. FORMCHECKBOX The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown. Based on the information you have provided to date, we are providing the following information about the amount of time that will be counted against your leave entitlement. FORMCHECKBOX Provided there is no deviation from your anticipated leave schedule, the above number of hours, days or weeks will be counted against your leave entitlement. The schedule approved is: FORMTEXT Full-time SPF Absence from April 12, 2010 through June 30, 2010. FORMCHECKBOX Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or weeks that will be counted against your FMLA entitlement at this time. You have the right to request this information once in a 30-day period (if leave was taken in the 30-day period). You may also view this information in ESS. The schedule approved is: FORMTEXT ?????Absence Type Information: FORMCHECKBOX You are required to use paid leave during your absence as described below. FORMCHECKBOX You have requested to use paid leave during FMLA leave and FORMDROPDOWN Absence. Any paid leave taken for this reason will count against your FMLA leave entitlement. FORMCHECKBOX The following absence types were requested to be used during this absence: FORMTEXT Prior to using unpaid SPF Absence, all accrued sick leave must be used. Following the exhaustion of your accrued sick leave, you have chosen to use accrued annual leave and anticipated sick leave prior to using unpaid SPF Absence. Based upon your request, your absence has been coded as: YS = SPF Sick Leave and YA = SPF Annual Leave.Return to Work Information: FORMCHECKBOX When released to return to full-duty work, please notify your supervisor and this office at least 24 hours in advance. FORMCHECKBOX You are required to submit a medical release that includes the date of release, prior to or immediately upon your return to work. Failure to submit a sufficient medical release may result in your return to work being delayed until certification is provided. A medical release to return to work with limitations must be reviewed and approved before you can return. The medical release must be directed to the SPF Absence Coordinator listed below. FORMCHECKBOX Based on your FORMDROPDOWN , you are expected to return to full-time, full-duty work on FORMTEXT July 1, 2010. Please notify the SPF Absence Coordinator listed below if you are unable to return on this date or are released to return sooner. ................
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