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<br />Form FMLA-4 <br /> <br />CITY OF PARIS <br />F AMIL Y AND MEDICAL LEAVE <br />SUPERVISOR'S FORM <br /> <br />TO BE COMPLETED BY SUPERVISOR AND PROVIDED TO THE EMPLOYEE <br /> <br />Name of Employee <br /> <br />Department: <br /> <br />This is to inform you that: <br /> <br />1. You are 0 eligible 0 are not eligible for leave under the FMLA. <br /> <br />2. The leave that you are taking 0 will 0 will not be counted against your annual FMLA leave <br />entitlement. <br /> <br />3 . You 0 will 0 will not be required to furnish a medical certification of a serious health condition by <br />. If certification is not received within 15 days of receiving this notice, <br />we may delay the commencement of your leave until certification is received. <br /> <br />4. You will be required to substitute accrued sick and vacation leave for unpaid FMLA leave. <br /> <br />5. You 0 will 0 will not be required to furnish us periodic reports every <br /> <br />6. You 0 will 0 will not be required to present a fitness-for-duty certificate prior to being restored to <br />employment. If such certification is required but not received, you will not be allowed to return to <br />active duty. <br /> <br />If you are on paid leave, your insurance premium will continue to be deducted from your salary warrant. If <br />you are on unpaid leave, you should submit your portion of your insurance premium to the Finance <br />Department no later than the 151 of each month. <br /> <br />Your Family and Medical Leave will begin (mld/yy) <br />Your FMLA unpaid leave begins (m/d/yy) <br /> <br />and end on <br /> <br />Signature of Supervisor <br /> <br />Date <br /> <br />Signature of Dept. Head <br /> <br />Date <br /> <br />71 <br /> <br />Revised 01-25-05 <br />