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The employer may also exercise the right to obtain a second or third opinion medical certification at the employer’s 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Continuous absencefrom work □ Intermittent absence from work*□I*Per schedule detailed in the FMLA Request Form  \nThe FMLA requires that you notify us as soon as practicable if dates ofscheduled leave change orare extended,or were initiallyunknown.Based on the information you have provided to date,and the current record ofyourtime and leave balance,the followingbreakdown of leaves willbe recorded.  \n# Type of Leave                      \n\nFrom  \nTo  \nType of Leave  \nFrom  \nType of Leave  \nFrom  \nType of Leave                          \nFrom  \n# Anticipated date of return                  \n\nIf your leaveisunscheduled,it will not be possible to provide the days that will be counted against your leave entitlement at this time.Youhave the right to request this information once ina 30-dayperiod(if leave was taken in the 30-day period).  \n# Fitness for Duty Certification\n\nYou will be required to present the \"Fitness for Duty\"Certification prior to being restored toemployment.If such certification is notreceived ina timely manner,your return to work may be delayed until such certification is provided.  \nA list of essential functions of your position/yourjob description has been provided to you.The \"Fitness for Duty\"Certification mustaddress your ability to perform the essential functions of your position.  \nYou will NOTberequired to present a \"Fitness for Duty\"Certification priorto being restored to employment.  \n# Periodic Reports\n\n□You will be required tofumish periodic reports of your status and intent to return to work every 30 days while on leave.  \n□You will NOT be required to fumish periodic reports of your status and intent to return to work every 30 days while on leave.  \n# Additional information is required to determine if your FMLA Leave Request can be approved\n\nThe certification you provided is not complete and sufficient to detemine whether the FMLA applies to your leave request and youmust provide the following information no later than the date specified,unlessit is not practicable under the particular circumstancesdespite your diligent good faith efforts,or yourleave may be denied.  \nAdditional information needed to make the certification complete and sufficient  \n# Submit additional infomation by          \n\nWe are exercising our right to have you obtain a second or third opinion medical certification at ourexpense &we will providefurtherdetails at a later time.  \nFAMILY AND MEDICAL LEAVE ACT(FMLA)-DESIGNATION NOTICE  \n□Your FMLA Leave is not approved  \nThe FMLA does not apply to your leave request  \n□You have exhausted your FMLA Leave entitlement in the applicable 12-month period  \nThis form must be signed by the Director of Human Resources or Designee  \nName  \nSignature  \nDate  \n\n| lfyou normally pay a portion ofyour health insurance,these payments must be made during your leave.Ifyouremain on payroll,your  \u003Cbr>premium deductionswill automaticallycontinue.If any part of your leave is or becomes unpaid,andyou normally contribute to your health  \u003Cbr>plan,information will be sent to you under separate cover outlining the proceduresnecessary for remitting payments to your health  \u003Cbr>insurance carrier.  \u003Cbr>CUNYwillcontinue to provide payment and will deductyour portion,if any,for pension contributions during the paid portion ofyour leave.  \u003Cbr>While on unpaid leave,pension contributions will not be made by the University.However,ifyou are a Tier 1member of the NYCTRS,any  \u003Cbr>unpaid FMLAleave may be creditable towards retirement benefits provided other eligibilityfactors are met.Please contact the College  \u003Cbr>Benefits Office for details.   |\n| --- |\n\nOHRM-FMLA DESIGNATION NOTICEFORM-2015","cbCaisrmlwLe9D3J","https://ap.wps.com/l/cbCaisrmlwLe9D3J","pdf",360794,"English","# Type of Leave\n## Anticipated date of return\n# Fitness for Duty Certification\n# Periodic Reports\n# Additional information required to determine approval\n## Submit additional information by\n# Health insurance and pension contributions","[{\"question\":\"What leave types does the FMLA designation notice cover?\",\"answer\":\"The notice records continuous absence and intermittent absence, based on the schedule provided in the FMLA request form. It also includes the breakdown of leave dates for the period of leave.\"},{\"question\":\"When is Fitness for Duty certification required?\",\"answer\":\"The notice states that Fitness for Duty certification is required prior to being restored to employment. If it is not received in a timely manner, the return to work may be delayed until the certification is provided.\"},{\"question\":\"What additional information may be required for the leave request to be approved?\",\"answer\":\"If the certification is not complete and sufficient, the employee must provide additional information by the specified date. The employer may also exercise the right to obtain a second or third opinion medical certification at the employer’s expense.\"}]","FMLA Designation Notice Form 2015 - Submit Fitness for Duty Certification - Periodic Reports Required | PDF",1789500252]