Massachusetts Family and Medical Leave Notice of Eligibility and Rights and Responsibilities Form

 Notice of Eligibility

TO:

[insert employee name]

FROM:

[insert employer representative name, title and department]

DATE:

[insert date]

On [insert date employee requested leave], you informed us that you needed leave beginning on [insert leave start date] for the following reason:

• The birth, adoption or foster care placement of a child and to bond with the child.
• Your own serious health condition (which may include pregnancy, childbirth and related medical conditions).
• To care for the following individual due to a serious health condition:
  • Spouse
  • Child
  • Parent
• A qualifying exigency arising out of the fact that following individual is on covered active duty or has been called to covered active duty as a member of the military reserves, National Guard or Armed Forces:
  • Spouse
  • Child
  • Parent
• You are the:
  • Spouse
  • Child
  • Parent
  • Next of kin (specify relationship): ____________________________________
    of someone who is:
    • An Armed Forces member (including the military reserves and National Guard) who is undergoing medical treatment, recuperation or therapy; is otherwise in an outpatient status; or is otherwise on the temporary disability retired list for a serious injury or illness incurred or aggravated in the line of duty while on active duty that may render the individual medically unfit to perform their military duties; or
    • A veteran (as defined by the Department of Veteran Affairs) who, during the five years prior to the treatment necessitating the leave, served in the active military, Naval or Air Service, and who was discharged or released under conditions other than dishonorable and who has a serious injury or illness incurred or aggravated in the line of duty while on active duty that manifested itself before or after the member became a veteran. For purposes of determining the five-year period for covered veteran status, the period between October 28, 2009, and March 8, 2013, is excluded.

This Notice is to inform you that you:

• Are eligible for leave under the federal Family and Medical Leave Act (FMLA).
• Are eligible for leave under the Massachusetts Parental Leave Act (MPLA).
• Are not eligible for leave under the FMLA because:
  • You have not met the 12-month length of service requirement. As of the date your requested leave is to begin, you will have worked approximately [insert number] months toward this requirement.
  • You have not worked 1,250 hours in the preceding 12 months. As of the date your requested leave is to begin, you will have worked approximately [insert number] hours toward this requirement.
  • There are fewer than 50 employees employed within a 75-mile radius of your location as of the date you requested leave.
  • You have exhausted the leave available to you under the FMLA.
• Are not eligible for leave under the MPLA because:
  • You have not worked for the Company in a full-time capacity for at least [insert number up to three] consecutive months. As of the date your requested leave is to begin, you will have worked approximately [insert number] months toward this requirement.
  • You have exhausted the eight weeks of leave available to you under the MPLA.

 Notice of Rights & Responsibilities

As explained in the Notice of Eligibility section above, you meet the eligibility requirements for taking one of the leaves described above and still have leave available in the applicable period. However, in order for the Company to determine whether your absence qualifies under the [insert applicable laws: FMLA and/or MPLA], you must provide the following accurate and timely information to Human Resources [or insert name/contact details for appropriate company representative or department] by [insert due date, which may not be fewer than 15 calendar days from the day the employee receives this notice]:

• Sufficient certification to support your request for leave. A certification form that sets forth the information necessary to support your request [insert: is or is not] enclosed.
• Sufficient documentation to establish the required relationship between you and your family member.
• Other information needed: [insert explanation of the information needed, e.g., documentation regarding a military exigency].
• No additional information requested.

If sufficient information is not provided in a timely manner, your leave may be delayed or denied.

If your leave does qualify under the [insert applicable laws: FMLA and/or MPLA], you will have the following responsibilities while on leave:

• You must confirm your leave start and end dates. You must also keep Human Resources [or insert name/contact details for appropriate company representative or department] informed of your current leave status.
• If you are receiving any pay from the Company while on leave, health insurance premiums will be deducted from that pay. If you are not receiving any pay from the Company during some or all of your leave, [insert one of the following paragraphs, as applicable:
  
  [Option 1 - you will be required to pay your portion of health insurance premiums while on leave. Contact Human Resources [or insert name/contact details for appropriate company representative or department] to make arrangements to continue to make your share of the premium payments to maintain health benefits while you are on leave. [Insert as applicable: If timely payment is not made, we will pay your share of the premiums during your leave, and will recover those payments from you upon your return to work. OR You have a minimum [insert number that is 30 or greater]-day grace period in which to make premium payments. If timely payment is not made, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share of the premiums during leave, and recover these payments from you upon your return to work.]]
  
  OR
  
  [Option 2 - we will pay your share of the premiums during your leave, and will recover those payments from you upon your return to work.]]
• If your leave is covered by the FMLA and/or MPLA, you are permitted to decide whether to use any available [insert applicable paid leave benefit types] to cover some or all of your leave. If you decide to use paid time off benefits available to you, you must complete and return the [insert names of applicable paperwork] to request the use of available paid time off benefits. The use of any available paid time off benefits will be considered part of your protected leave and will be counted against your leave entitlement.
• Due to your status with the Company, you are considered a key employee as defined by the FMLA. As a key employee, restoration to employment may be denied following leave on the grounds that such restoration will cause substantial and grievous economic injury to the Company. We determined that restoring you to employment at the conclusion of FMLA leave [insert: will or will not] cause substantial and grievous economic harm to the Company.
• If leave is due to your own medical condition, you must submit to the Company a health care provider's medical certificate showing that you are able to return to work and that you can safely perform all of the essential functions of your position (as they relate to your medical condition), with or without reasonable accommodation and/or restrictions.

If the circumstances of your leave change, and you are able to return to work earlier than the date you originally indicated, you must notify Human Resources [or insert name/contact details for appropriate company representative or department] at least two business days prior to the date you intend to report for work.

If your leave does qualify under the [insert applicable laws: FMLA, MPLA], you will have the rights below that correspond with the leaves for which you qualify:

• You have a right under the FMLA to up to 12 weeks of unpaid leave in a 12-month period for: (1) the birth, adoption or foster care placement of a child and bonding with the child; (2) caring for a family member with a serious health condition; (3) your own serious health condition (which may include pregnancy, childbirth and related medical conditions); and (4) military exigencies. A 12-month period is calculated as [insert FMLA measurement period].
• You have a right under the FMLA to up to 26 weeks of unpaid leave in a single 12-month period for military caregiving. This single 12-month period [insert: began or begins] on [insert date].

• You have a right under the MPLA to up to eight weeks of unpaid leave for the birth or adoption of a child.

  In some circumstances, the use of MPLA leave may run concurrently with the use of FMLA leave.

• If you are on leave under the FMLA and/or MPLA, your health benefits will be maintained during your protected leave under the same conditions as if you continued to work.
• Under the FMLA and/or MPLA, you will be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from protected leave. However, you have no greater right to reinstatement than if you had continued to work. For example, if you would have been laid off had you not gone on leave or if your position has been eliminated during your leave, you will not be entitled to reinstatement. If your absence extends beyond your protected leave entitlement, you do not have reinstatement rights under the FMLA and/or MPLA. For avoidance of doubt, if you are not eligible for FMLA leave and take only MPLA leave, any period of that leave that extends beyond eight weeks is not job protected.
• If you do not return to work following your FMLA leave for a reason other than:  (1) the continuation, recurrence or onset of a serious health condition or disability that would entitle you to leave under the FMLA; (2) the continuation, recurrence or onset of a covered servicemember's serious injury or illness that would entitle you to FMLA leave; or (3) 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 leave.
• If the Company's policy allows for you to take paid time off benefits during a leave of absence, you have the right to have accrued paid time off benefits run concurrently with your unpaid leave entitlement(s), provided you meet any applicable requirements of the Company leave policy. If you do not meet the requirements for taking paid time off benefits, you remain entitled to take unpaid leave.