FMLA FORMS

GUARDIAN ANGEL FAMILY MEDICAL LEAVE INSTRUCTIONS AND FORMS
 
When a Guardian Angel employee becomes aware of a need for family or medical leave you must provide thirty (30) days in advance notice where feasible, and complete and return the following forms to Guardian Angel’s Human Resources Department:
 
*Click the highlighted links to view and print the appropriate FMLA Forms*
 
You may also stop by our office during normal working hours or request a copy of these forms to be mailed to your home.
 
It is the YOUR RESPONSIBILITY AS THE EMPLOYEE to complete and return the appropriate forms to Guardian Angel’s Human Resources Department in order for an FMLA Eligibility Determination to be made.

 
STEP 1:
Employees must complete and return the Request for Family/Medical Leave Form.
• Employees are encouraged to read the Employee Rights & Responsibilities regarding FMLA Eligibility Requirements.

 
STEP 2:
Under the guidelines of the The Family Medical Leave Act (FMLA), Guardian Angel Staffing Agency, Inc., reserves the right to require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider.
 
If an Employee is requesting FMLA for their own Serious Health Condition the employee must complete and return:
WH-380-E: Certification of Health Care Provider for Employee’s Serious Health Condition
• Employee’s must complete Section II of Form WH-380-E
• Your Health Care Provider must complete Section III of Form WH-380-E
 
If an Employee is requesting FMLA for a Family Member’s Serious Health Condition the employee must complete and return:
WH-380-F: Certification of Health Care Provider for Family Member’s Serious Health Condition
• Employee’s must complete Section II of Form WH-380-F
• Your Health Care Provider must complete Section III of Form WH-380-F

 
STEP 3 MILITARY FMLA REQUEST (If Applicable):
If an Employee is requesting FMLA due to a qualify exigency for Military Family Leave the employee must complete and return:
WH-384: Certification of Qualifying Exigency For Military Family Leave
• Employee’s must complete Section II of Form WH-384
Please note a complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a military member’s covered active duty or call to covered active duty status.
 
If an Employee is requesting FMLA for a Serious Injury or Illness of a Current Service Member- for Military Family Leave the employee or current service member must complete and return:
WH-385: Certification for Serious Injury or Illness of a Current Service Member
• Employee’s or Current Service Member must complete Section I of Form WH-385
• The United States Department of Defense (“DOD”) Health Care Provider or a Health Care Provider who is either: (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD Tricare network authorized private health care provider; (3) a DOD non-network Tricare authorized private health care provider; or (4) a health care provider as defined in 29 CFR 825.125 must complete Section II of Form WH-385
 
If an Employee is requesting FMLA for a Serious Injury or Illness of a Veteran for Military Caregiver Leave the employee and/or Veteran must complete and return:
WH-385-V: Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave
• Employee’s and/or Veteran must complete Section I of Form WH-385-V
• Section II is for completion by: (1) a United States Department of Defense (“DOD”) health care provider; (2) a United States Department of Veterans Affairs (“VA”) health care provider; (3) a DOD Tricare network authorized private health care provider; (4) a DOD non-network Tricare authorized private health care provider; or (5) a health care provider as defined in 29 CFR 825.125 must complete Section II of Form WH-385-V
 
Employees must complete and return the following to
Guardian Angel’s Human Resources Department:
• Family/Medical Leave Form (Step 1)
• The appropriate Certification of Health Care Provider Form (Step 2)
• Qualifying Exigency Form (Step 3)-For Military Family Leave (If Applicable)
• Military Serious Injury or Illness of Current Service Member Form WH-385, and or Serious Injury or Illness of a Veteran for Military Caregiver Leave WH-385-V (If Applicable)
Medical Certification must be returned within 15 days of request for leave, or as soon as practical.

 
Step 4:
After the completed Request for Family/Medical Leave Form (Step 1), and the appropriate Certification of Health Care Provider Form (Step 2), and (Step 3, if applicable) has been completed by the employee, and received/reviewed by Guardian Angel’s Human Resources Department, Guardian Angel will then complete the Notice of Eligibility and Rights & Responsibilities WH-381 Form and the Designation Notice WH-382 form, and give to the employee approving of denying FMLA leave.
 
WH-381: Notice of Eligibility and Rights & Responsibilities
• To be completed by Guardian Angel Human Resources department
 
WH-382: Designation Notice
• To be completed by Guardian Angel Human Resources Department
 
Employees on approved FMLA leave also are required to check in with Guardian Angel’s Human Resources Department regarding their status and intention to return to work. Your periodic reports will be documented utilizing the Schedule of Employee Periodic Reports Log.
 
Employees on approved FMLA leave may continue health coverage while on FMLA leave; provided the employee continues making the same weekly premium contribution that was made prior to taking leave.
 
Employees must provide proper notification of intent to return from FMLA leave to Guardian Angel’s Human Resources Department at least five (5) days prior to the employee’s planned return by completing the Return to Work Medical Certification Form. When returning from FMLA leave, employees will be restored to their original position or to a position with equivalent duties, pay, benefits and other terms and conditions of employment.

 
Please contact Guardian Angel’s Human Resources Department for any additional questions regarding family medical leave at (502) 495-1199.