Below is the  Response To Employee Request For Family Or Medical Leavetemplate body. If necessary, please put the personal information, company information, such as text to replace the specific content you need. you can download the .doc template file on the end of the article by click download link. 

RESPONSE TO REQUEST FOR FAMILY 
OR MEDICAL LEAVE OF ABSENCE



Employee Name:
Date:

Department:
Title:



On [DATE] you notified us of your need to take family/medical leave due to:

The birth of a child or the placement of a child for adoption or foster care; or
A serious health condition that you need care for; or
A serious health condition affecting your spouse/child/parent, for which you are needed to provide care.


You requested leave beginning [DATE] and ending on or about [DATE].

This is to inform you that (check appropriate boxes):

1.  You are ( eligible ( not eligible for leave under the FMLA (Family/Medical Leave of Absence).

2.  The request leave ( will ( will not be counted against your annual FMLA leave entitlement.

3.  You ( will ( will not be required to furnish medical certification of a serious health condition. If required, you must furnish certification by [DATE] (must be within 15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted.

4.  You may elect to substitute accrued paid leave for unpaid FMLA leave. We ( will ( will not require that you substitute accrued paid leave for unpaid FMLA leave. If paid leave will be used, the following conditions will apply:
                                                                        
If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of your FMLA leave. Arrangements for payment have been discussed with you and it is agreed that you will make the premium payments as follows:
                                                                              

You have a [NUMBER] day grace period in which to make payment. If payment has not been made within that period, your group health insurance may be canceled, or, at our option, we may pay your share of the premiums during FMLA leave, and recover these payments from you upon your return to work. 
We ( will ( will not pay your share of the premiums for your health insurance while you are on leave. We ( will ( will not do the same with other benefits (e.g. life insurance, etc.) while you are on FMLA leave. If we do, when you return from leave you will be expected to reimburse us for the payments made on your behalf.

7.  You ( will ( will not be required to present a fitness-for-duty certificate prior to being restored to employment. If such certification is required but not received, your return may be delayed until such certification is provided.

8.  You ( are ( are not a key employee as described in the FMLA regulations. If you are a key employee, restoration to employment may be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us as follows:
                                                                        

9.  We ( have ( have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to us as follows:
                                                                        

10.  You ( will ( will not be required to furnish us with periodic reports of your status and intent to return to work every [Number] days while on FMLA leave.

11.  You ( will ( will not be required to furnish recertification every [NUMBER] days relating to a serious health condition:

Except as explained above, you have a right under the FMLA for up to [NUMBER] weeks of unpaid leave in a [NUMBER] month period for the reasons listed above. Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work, and you must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from leave. If you do not return following FMLA leave for a reason other than: 1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave; or 2) other circumstances beyond your control, you may be required to reimburse the company for its share of health insurance premiums paid on your behalf during your FMLA leave.



Signature:
Date

Department:
Title:



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