Resolution No. 9731in
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RESOLUTION NO. 9731
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING AND ADOPTING A REVISED CITY OF
VERNON FAMILY AND MEDICAL LEAVE POLICY
WHEREAS, on October 17, 1995, the City Council of the City
of Vernon adopted Resolution No. 6696 approving and adopting a Family
and Medical Leave Policy (the "FMLA Policy") and
WHEREAS, since the adoption of the FMLA Policy, the City has
adopted revisions or amendments, the latest revision being adopted on
November 5, 2003, by Resolution No. 8297; and
WHEREAS, the Director of Human Resources has recommended that
the FMLA Policy be revised to ensure compliance with all City of Vernon
procedures and policies and all State and Federal laws.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF VERNON AS FOLLOWS:
SECTION 1: The City Council of the City of Vernon hereby
finds and determines that the recitals contained hereinabove are true
and correct.
SECTION 2: The City Council of the City of Vernon hereby
approves and adopts the revised City of Vernon Family and Medical Leave
Policy, a copy of which is attached hereto as Exhibit A and
incorporated by reference.
SECTION 3: The City Council of the City of Vernon hereby
declares that all prior drafts of the FMLA Policy have never been
approved, authorized, or in any way ratified by the City Council and,
therefore, have no force or effect.
SECTION 4: The City Council of the City of Vernon hereby
1 authorizes the Director of Human Resources, or her designee, to inform
2 City employees about the provisions of the revised FMLA Policy.
3 SECTION 5: The City Council of the City of Vernon hereby
4 authorizes and empowers the Director of Human Resources, or her
5 designee, to make whatever nonsubstantive and administrative changes,
6 upon advice of counsel, to the FMLA forms attached to the FMLA Policy
7 as are necessary to carry out the intent of this Resolution.
8 SECTION 6: All resolutions or parts of resolutions in
9 conflict with this resolution are hereby repealed.
10 SECTION 7: The City Clerk of the City of Vernon shall
11 certify to the passage of this resolution, and thereupon and
12 thereafter the same shall be in full force and effect.
13 APPROVED AND ADOPTED this 6th day of October, 2008.
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15 Name: Leonis C. Malburg
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Title: Mayor
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18 ATTEST:
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20 MAN ELA GIRON,Clitty Clerk
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STATE OF CALIFORNIA )
) ss
COUNTY OF LOS ANGELES )
I, MANUELA GIRON, City Clerk of the City of Vernon, do hereby
certify that the foregoing Resolution, being Resolution No. 9731, was
duly adopted by the City Council of the City of Vernon at a regular
meeting of the City Council duly held on Monday, October 6, 2008, and
thereafter was duly signed by the Mayor or Mayor Pro-Tem of the City of
Vernon.
(SEAL)
MANUELA GI ON, City Clerk
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EXHIBIT A
CITY OF VERNON
FAMILY AND MEDICAL LEAVE POLICY
(Amended October 6, 2008)
I. STATEMENT OF POLICY
In accordance with the California Family Rights Act, ("CFRA")(Government Code Section
12945.2) and the Federal Family and Medical Leave Act of 1993 ("FMLA")(Title 29 U.S. Code,
Sections 2601 et seq.), the City of Vernon will grant job protected unpaid family and medical
leave to eligible employees for up to 12 weeks per 12-month period (or in certain circumstances
as stated below, for 26 weeks per 12-month period) for any one or more of the following reasons:
A. The birth of a child and in order to care for such child or the placement of a child with the
employee for adoption or foster care (leave for this reason must be taken within the 12-
month period following the child's birth or placement with the employee); or
B. In order to care for an immediate family member (spouse, child, or parent) of the
employee if such immediate family member has a serious health condition; or
C. The employee's own serious health condition that makes the employee unable to perform
the functions of his/her position; or
D. Serious health condition related to pregnancy; or
E. "Qualifying Exigency" Family Military Leave to "any qualifying exigency (as the
Secretary [of Labor] shall, by regulation, determine) arising out of the fact that the
spouse, or a son, daughter, or parent of the employee is on active duty (or has been
notified of an impending call or order to active duty) in the Armed Forces in support of a
contingency operation; or
F. "Injured Servicemember" Family leave to care for "spouse, son, daughter, parent, or next
of kin to take up to 26 workweeks of leave to care for a "member of the Armed Forces,
including a member of the National Guard or Reserves, who is undergoing medical
treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on
the temporary disability retired list, for a serious injury or illness."
II. DEFINITIONS
A. "12-Month Period" — means a rolling 12-month period measured backward from the date
leave is taken and continuous with each additional leave day taken.
B. "Spouse" — does not include unmarried domestic partners. If both spouses work for the
City of Vernon their total leave in any 12-month period may be limited to an aggregate of
12 weeks if the leave is taken for either the birth or placement for adoption or foster care
of a child or to care for a sick parent. (CFRA does include registered domestic partners).
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C. "Child" — means a "biological, adopted or foster child, a step child, a legal ward, or a
child of a person standing in loco parentis... "child either under 18 years of age, or 18
years of age or older who is incapable of self -care because of a mental or physical
disability. An Employee's "child" is one for whom the employee has actual day-to-day
responsibility for care and includes a biological, adopted, foster or step -child.
D. "Parent" — means the biological parent of an employee or an individual who stands or
stood in'loco parentis to the employee when the employee was a child.
E. "Serious Health Condition" — means an illness, injury, impairment, or a physical or
mental condition that involves:
Inpatient care (for example, an overnight stay) in a hospital, hospice, or residential
medical care facility, including any period of incapacity; or any subsequent
treatment in connection with such in patient care; or
2. Continuing treatment by, or under the supervision of a health care provider.
3. Cosmetic/elective/voluntary treatment IS NOT a Serious Health Condition which
is protected under FMLA.
F. "Continuing Treatment" —means:
Any period of incapacity requiring absence from work for more than,three
consecutive calendar days AND any subsequent treatment or period of incapacity
relating to the same condition that also involves:
(i) Treatment two or more times by a health care provider, or by a nurse, or by a
physician's assistant under direct supervision of a health care provider, or by a
provider of health care services (e.g. physical therapist) on referral from a health
care provider; or
(ii) Treatment by a health care provider on at least one occasion which results in a
regimen of continuing treatment (a "regimen of continuing treatment" includes a
course of prescription medication or therapy requiring special equipment, but
does not include over-the-counter medications, drinking fluids, or exercise);
2. Pregnancy (but only for FMLA leave that runs concurrently with PDL);
3. Incapacity due to a_ chronic -serious health condition such as asthma, diabetes, or
epilepsy, or treatment for such incapacity;
4. Incapacity due to a long-term condition for which treatment may not be effective,
such as Alzheimer's or the terminal stages of a disease; and/or
Absences to receive multiple treatments by a health care provider, including
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recovery from treatments, such as chemotherapy, radiation, physical therapy for
severe arthritis, restorative surgery after an accident, and kidney dialysis.
III. COVERAGE AND ELIGIBILITY
A. To be eligible for family/medical leave an employee must:
1. Have worked for the City of Vernon for at least 12 months, which need not be
consecutive months; and
2. Have worked at least 1250 hours over the previous 12 month period.
IV. INTERMITTENT OR REDUCED LEAVE
A. An employee may take leave "intermittently" (minimum of Ihour, up to a few days) or
on a reduced leave schedule to care for an immediate family member with a serious
health condition or because of a serious health condition of the employee when
"medically necessary."
1. "Intermittent leave" would require, for example, an employee leaving 10 minutes
before the end of the workday to obtain treatment for a serious health condition to
use 1 hour of his/her family leave entitlement.
2. "Medically necessary" means there must be a medical need for the leave and that the
leave can be best accomplished through an intermittent or reduced leave schedule.
3. The employee may be required to transfer temporarily to a position with equivalent
pay and benefits that better accommodates recurring periods. of leave when the leave
is planned based on scheduled medical treatment.
B. For part-time employees who are eligible and those employees who work variable hours
and are eligible, the family and medical leave entitlement is calculated on a pro rata basis.
A weekly average of the hours worked over the 12 weeks prior to the beginning of the
leave should be used for calculating the employee's normal workweek.
V. SUBSTITUTION OF ACCRUED LEAVE
For FMLA leaves of absence that are based on an employee's own serious health condition,
employees are required to use their accrued leaves included but not limited to paid sick leave
first and then accrued vacation time for any part of a family/medical leave. If the FMLA leave is
for one of the other qualifying events, employees are required to use accrued paid vacation time
for any part of a family/medical leave taken for any reason. The accrued paid time. runs
concurrently with the family and medical leave. If employee chooses to use comp time that
period of time is not counted as FMLA time.
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Use of accrued time is mandatory even if employee has supplemental disability insurance.
VI. EMPLOYEE NOTICE OF LEAVE
Although the City of Vernon recognizes that emergencies arise which may require employees to
request immediate leave, employees are required to give as much notice as possible of their need
for leave. If leave is foreseeable, at least 30 days notice is required. In addition, if an employee
knows that he/she will need leave in the future, but does not know the exact date(s) (e.g. for the
birth of a child or to take care of a newborn), the employee shall inform his/her supervisor as
soon as possible that such leave will be needed. The Supervisor/Manager and/or the Department
Head should notify the Director of Human Resources as soon as they learn of an employee's
request for FMLA leave of absence and should also direct the employee to the Director of
Human Resources for information and forms regarding the same. If an employee notifies a
supervisor of any extended leave of absence, the same policy applies. If the City of Vernon
determines that an employee intentionally fails to give notice or if the City of Vernon determines
an employee's notice is inadequate or the employee knew about the requested leave in advance
of the request, the City of Vernon may delay the granting of the leave until it can, in its
discretion, adequately cover the position with a substitute.
If the need for leave is unforeseeable, the employee is required to give notice within 1-2 days
after leave commences.
Notice of the need for the leave can be verbal or in writing.
City of Vernon will make a written record of the FMLA notification and will give notice to
Department Heads, payroll and supervisors simultaneously.
VII. WORKERS COMPENSATION
Although FMLA leaves of absence are generally unpaid leaves of absence there are exceptions
when an FMLA leave of absence overlaps with a leave of absence due to an injury on the job.
Public Safety employees are entitled to full pay and full benefit accruals after sustaining an
injury on the job for one full year. Therefore, FMLA leaves of absence do not commence until
after a public safety employee has completely utilized their 1-year statutory leave under section
4850.
Miscellaneous employees who are injured on the job are provided with a 90-day salary
continuance and placed on FMLA concurrently but are still not entitled to accrue paid leaves
such as sick or vacation benefits during this time period.
VIII. MEDICAL CERTIFICATION
Employees who request leave for their own serious health condition or to care for a child, parent,
or a spouse who has a serious health condition must provide written certification from the health
care provider of the individual requiring care to the Risk Management Department. If the leave
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is requested because of the employee's own serious health condition, the certification must
include a statement that the employee is unable to perform the essential functions of his/her
position. The certification must indicate that the health care provider has reviewed the
employee's job description; must contain information regarding the length of time the condition
is expected to last, as well as the specific restrictions resulting from the condition.
If the City of Vernon has reason to doubt the validity of a certification regarding the employee's
serious health condition, the Office of Risk Management and or the Director of Human
Resources may require a medical opinion of a second health care provider chosen by the City of
Vernon. If the second opinion is different from the first, the City of Vernon may require the
opinion of a third provider jointly approved by the City of Vernon and the employee. The
opinion of the third provider will be binding. Certification of medical condition of parent, child
or spouse must be accepted if properly filled out. No second or third opinions are permissible.
Employee will have 15 days to provide medical certification otherwise the FMLA leave may be
denied.
If an employee is requesting Injured Servicemember Leave, the employee must provide
certification of serious injury or illness from Department of Defense or Department of Veterans
Affairs.
If an employee requests leave intermittently (minimum of lhour, up to a few days) or on a
reduced leave schedule to care for an immediate family member with a serious health condition,
the employee must provide medical certification that such leave is medically necessary.
"Medically necessary" means there must be a medical need for the leave and that the leave can
best be accomplished through an intermittent or reduced leave schedule.
Recertification must be provided within 30-days upon request by the City. No second or third
opinions are permissible for purposes of recertification.
IX. AFFECT ON ,BENEFITS
An employee granted a leave under this policy will continue to be covered under the City of
Vernon group medical/dental/vision insurance plans and life insurance plan under the same
conditions as coverage would have been provided if they had been continuously employed
during the leave period (up to 12 or 26 weeks depending on the issue giving rise to the leave).
However, if an employee makes contributions for any kind of medical and/or supplemental
insurance, the employee will still be expected to make those contributions on a timely basis or
will risk cancellation from the plan.
Additionally, employee will still be responsible for making any payments to the City of Vernon
for any loans that are normally deducted from an employee's paycheck.
If an employee fails to return from unpaid family/medical leave for reasons other than (1) the
continuation of a serious health condition of the employee or a covered family member or (2)
circumstances beyond the employee's control (certification required within 30 days of failure to
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return for either reason), the City of Vernon may seek reimbursement from the employee for the
premiums paid by the City of Vernon on behalf of that employee during the leave.
An employee does not accrue seniority and is not entitled to employment benefit accrual during
periods of unpaid leave; this includes longevity, annual merit increase consideration and
vacation. However, the employee will not lose any seniority or benefits which were accrued
prior to the unpaid family/medical leave.
X. JOB PROTECTION/REINSTATEMENT
If an employee returns to work within the time permitted by this policy following the
commencement of family/medical leave, he/she will be reinstated to his/her former position or an
equivalent position with equivalent pay, benefits, status and authority.
Employee's restoration rights are the same as they would have been had the employee not been
on leave. Thus, if an employee's position would have been eliminated or the employee would
have been terminated but for the leave, the employee would not have the right to be reinstated
upon return from leave.
If an employee fails to return within the time permitted by this policy following a family/medical
leave the employee will be reinstated to his/her same or similar position, only`if available. If the
employee's same or similar position is not available, the employee may be terminated.
Additionally, an employee whose FMLA expires but is still seriously injured may have job
protection under the American with Disability Act and/or the California Department of Fair
Employment and Housing.
XI. REQUIRED FORMS
"Leave Request Form" prepared by the employee seeking the leave must be turned in to
the Risk Management Office prior to the Leave if employee has pre-existing knowledge
of the leave;
2. "Certification of Health Care Provider" — For the employee's own serious health
condition
"Physician Or Practitioner Certification Family Member — Serious Health Condition" -
For the serious health condition of a child, parent or spouse;
4. "Fitness For Duty" to return from leave form.
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LEAVE REQUEST FORM
LEAVE REQUEST FORM 1
LEAVE REQUEST- FORM
1. 2.
Employee Name (print clearly) Social Security Number (print clearly)
3. Reason for Leave (check all that apply):
a. ❑
Birth of a child of the employee or the employee's registered. domestic partner and to care for
the -'newly -born child, or. placement of a child with the employee and/or the 'employee's
registered domestic partner for adoption or faster care
b. ❑
To care for an immediate family member. (spouse, registered domestic partner, child,
registered domestic partner's child, or employee's parent) with.le serious health condition
c. ❑
Because of the employee's serious health condition (including pregnancy related disability)
d. ❑
Personal
e. ❑
Other: (pdnldeadV)
4. Type Of Leave Requested For The Purpose Identified Above (check all that apply, If available)
a. ❑ Paid Vacation
b. ❑ Accrued Paid Medical/Sick leave
C. ❑ Unpaid Famlly and Medical Leave
d. ❑ Pregnancy Disability Leave
e. ❑ Other: mdNcteadv,
YOU MAY NOT UTILIZE CERTAIN TYPES OF PAID LEAVE IF WE DO NOT NORMALLY
PRow,DE PAID LEAVE FOR THE PURPOSE OF rHE LEAVE YOU REQUESTED.
5. Is intermittent leave or reduced
work schedule requested?
If yes, explain why It Is needed and the
leave schedule proposed:
6. Intention To Return To Work When The Leave Ends (select one):
a. ❑ Employee will not be returning to work
b. ❑ Employee intends to return to work. .
7. a. Date leave expected to begin'
b. Date leave expected to and
B. Name of person who provided
information to complete form:
(if other than employee) (Pan' nleerty)
9. Name of person who completed form: -
Date: (print clearly)
I certify that the above information is true and correct to the best of my knowledge. 'I understand
that any misrepresentation concerning the.above facts can result in termination of.employmenL,
Employee Name
Leave Request Form
Date
page I of 1
CERTIFICATION OF HEALTH CARE PROVIDERFORM
CERTIFICATION OF HEALTH CARE PROVIDERFORM 2
Certification of Health Care Provider
(Family and Medical Leave Act of 1993)
U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division •'
(When completed, this form goes to the employee, Not to the Department of labor.)
1. Employee's Name
OMB No.: 1215-0181
Expires: 09-30-2010
2. Patient's Name (if different from employee)
3. Page 4 describes what is meant by a "serious health condition" under the Family and Medical Leave Act. Does the
patient's condition' qualify under any of the categories described? If so, please check the applicable category.
(1) (2) (3) (4) (5) (6) , or None of the above
4. Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet
the criteria of one of these categories:
6. a. State the approximate date the condition commenced, and the probable duration of the condition (and also the
probable duration of the patient's present Incapacity2 if different):
b. 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:
c. if the condition is a chronic condition (condition #4) or pregnancy, state whether the patient is presently incepacitated2
and the likely duration and frequency of episodes of incapacity2:
1 Here and elsewhere on this form, the Information sought relates only to the condition forwhich 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 dolly activities due to the serious health
condition, treatment therefor, or recovery therefrom.
Form wH-WO
Page 104 nwhed December IM
6. ,a. 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 activitles because of treatment on an intermittent or part-time
basis, also provide an estimate of the probable dumber of and interval between such treatments, actual or estimated
dates of treatment If known, and period required for recovery If any:
b. 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:
c. If a regimen 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):
••��• G. ,�a.� 1�4ullwu SYP 1110 cuiployee s aosence Trom 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?
b. If able to perform some work, Is the employee unable to perform anyone 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 employee is unable to perform:
c. if neither a. nor b. applies, Is it necessary for the employee to be absent from work for treatment?
8. a. 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?
b. If no, would the employee's presence to provide psychological comfort be beneficial to the patient or assist in the
patient's recovery?
c. 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
Address
Type of Practice
Telephone Number
Date
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 Signature
fte3d4
Date
A"Serious Health Condition" means an illness, Injury Impairment, or physical or mental condition that involves one of the
following:
1011111"M
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.
2. AbsencePlusTreatment
(a) A period, of incapacity2 of more than three consecutive calendar days (including any subsequent treatment or
period of Incapacity2 relating to the same condition), that also involves:
(1) Treatment3 two or more times by a healthcare 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
(2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing
treatment'l under the supervision of the health can: provider.
3. Pregnancy
Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Conditions RequldrigTreatments
A chronic condition which:
(1) 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;
(2) Continues over an extended period of time (Including recurring episodes of a single underlying condition);
and
(3) May cause episodic rather than a continuing period of incapacity2 (e.g., asthma, diabetes, epilepsy, etc.).
5. PermanentlUng-term Conditions Requiring Supervision
A period of incapacity2 which is permanent or long-term due to a condition for which treatment may not be effective. The
employee orfamily member must be under the 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.
6. Multipir, Treatments (Non-ChronicConditions)
Any period of absence to receive multiple treatments (Including any period of recovery therefrom) by a healthcare ,
provider or by a provider of healthcare 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 incapacity2
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), and kidney disease (dialysis).
This optional form may be used by employees to satisfy a mandatory requirement to furnish a medical certification (when requested) from
a health care provider, including second or third opinions and recertification (29 CFR 825.306).
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
s Treatment Includes examinations to determine ff a serious health condition exists and evaluations of the conditlon. Treatment does not include routine
physical examinallons, eye examinations, ordental examinations.
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 ar allevlate the hearth condition. A regimen of treatment does not Include the taking of over-the-counter medications such as aspirin,
antihistamines, or salves; or bad -rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.
Public Burden Statement
We estimate that it will take an average of 20 minutes to complete this collection of Information, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, Department
of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND ME COMPLETED FORM TO THiS OFFICE; IT GOES TO THE EMPLOYEE.
Pepe 4 of 4 *U.S. GPO: 200WB7.954l255M
PHYSICIAN OR PRACTITIONER CERTIFICATION FAMILY
MEMBER - SERIOUS HEALTH CONDITION FORM
PHYSICIAN OR PRACTITIONER CERTIFICATION
FAMILY MEMBER- SERIOUS HEALTH CONDITION FORM 3
PHYSICIAN OR PRACTITIONER CERTIFICATION
FANHLY MEMBER — SERIOUS HEALTH CONDITION
Employee's Name:
2. Patient's Name:
3. Does the employee's child, parent, or spouse have an illness, injury, impairment, or
physical or mental condition which constitutes a "serious health condition." A "serious
health condition" is described.on the attached sheet (attachment 'W). Does the patient's
condition qualify under any of the categories described? If so, please check the
applicable category.
(1) (2) (3) (4) (5) (6) . or None of the above.
4. Date medical condition or need for treatment commenced:
5. Probable duration of medical condition or need for treatment:
6. Regimen of treatment to be prescribed (indicate number of visits, general nature and
duration of treatment, including referral to other provider of health services. Include
schedule of visits or treatment if it is medically necessary for the employee to be off work
on an intermittent basis or to work less than the employee's normal schedule of hours per
day or days per week).
A. By Physician or Practitioner:
B. By other provider of health serApes, if referred by Physician or Practitioner:
Check Yes or No in the space below, as appropriate.
7. Yes_ No Is inpatient hospitalization of the family member (patient)
required?
8. Yes— No Does (or will) the patient require assistance for basic
medical, hygiene, nutritional needs, safety or
transportation?
9. Yes_ No After review of the employee's signed statement (see
Item 11 below), is the employee's presence necessary or
would it be beneficial for the care of the patient? (This
may include psychological comfort and/or the arranging for
third party care for the family member.)
10. Estimate the period of time care that is needed or the employee's presence would be
beneficial:
ITEM 11 TO BE COMPLETED BY THE EMPLOYEE REQUESTING FAMILY
LEAVE
11. When Family Leave is needed to care for a seriously ill family member, the employee
shall state the care he or she will provide and an estimate of the time period during which
this care will be provided, including a schedule if leave is to be taken intermittently or on
a reduced leave schedule:
Employee Signature: Date:
12. Signature of Physician or Practitioner:
13. Date:
14. Type of Practice (Field of Specialization, if any):
SERIOUS HEALTH CONDITION
A "Serious Health Condition" means an illness, injury, impairment, or physical or mental condition that involves one of the
following:
Hospital Care
Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of
incapacity or subsequent treatment in connection with or consequent to such inpatient care.
Absence Plus Treatment
(a) 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:
(1) Treatment[ 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
(2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing
treatmene under the supervision of the health care provider.
Pregnancy
Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Conditions Requiring Treatments
A chronic condition which:
(1) Requires periodic visits for treatment by a health care provider, or by a nurse physician's assistant under
direct supervision of a health care provider;
and
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition);
(3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.)
Permanent/Long Tenn 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 the continuing supervision of, but need not be receiving active treatment by, a health
care provider. Lxamples include Alzheimer's a severe stroke, or terminal stages of a disease.
Multiple Treatments (Non -Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by
Et provider of health care services under orders, of, or any 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).
1 Treatment includes examination to determine if a serious condition exists and evaluations of the condition.
Treatment does not include routine physical examinations, eye examinations, or dental examinations.
2 A regimen of continuing treatment includes, for example, a course of prescription medicine (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 of 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.
Serious Health Condition Attachment "A"
FITNESS FOR DUTY TQ RETURN FROM EMPLOYEE'S
MEDICAL LEAVE CERTIFICATIONFORM
FITNESS FOR DUTY TO RETURN FROM EMPLOYEE'S
MEDICAL LEAVE CERTIFICATION FORM L�
FITNESS FOR DUTY TO RETURN FROM EMPLOYEE'S
MEDICAL LEAVE CERTIFICATION
On ,
date employee commenced leave for serious health condition
leave from
employee's name
Name of Agency or Employer
Based on my review of
job description title
began a period of medical
job description as a
employee's name
and my physical examination of
employee name
on
date of medical examination of employee
medically/psychologically fit to return to
with the following limitations:
date
Next Scheduled Visit:
date
I certify that he/she is
on
employee's job
list limitations if applicable
Date:
Signature of Physician or Practitioner
Type of Practice (Field or Specialization, if any)
CITY CLERK'S OFFICE
INTEROFFICE MEMORANDUM
DATE: October 21, 2008
TO: Rory Burnett, Finance,Director
Sharon Duckworth, City Treasurer
Avigal Horrow, Human Resources Director
Donal O'Callaghan, Director of Light & Power
Lewis Pozzebon, Director of Environmental Health
Steve Towles, Chief of Police
Martha Valenzuela, Director of Personnel/Purchasing Agent
Mark Whitworth, Fire Chief
Kevin Wilson, Director of Community Services & Water
Willard Yamaguchi, Chief Deputy City Attorney/Risk Manager
FROM: Nelly Giron, City Clerk
RE: Resolution No. 9731 - A Resolution of the City Council of
the City of Vernon Approving and Adopting a Revised City of
Vernon Family and Medical Leave Policy
Transmitted herewith is a copy of Resolution No. 9731 referenced
above, which was approved by City Council on October 6, 2008.
Thank you.
NG:dr
c: Resolution No. 9731