Family Medical Leave of Absence (FMLA)

Eligibility

To be eligible for coverage under the FMLA, an employee must have worked for the City for at least 1,250 hours during the preceding twelve (12) month period. In other words, the hours of service requirement will be met if an employee has worked a total of 1,250 hours of service in the twelve (12) months immediately preceding the start of the FMLA leave. In determining whether an employee has met the 1,250 hours requirement, it is important to note that:

• Only the time actually worked, including overtime hours worked, is counted. Time not actually worked, including vacation, personal leave, sick leave, holidays, and any other form of paid time off (PTO), is not counted towards the 1,250 hours of service. Unpaid leave of any kind or periods of layoff are not counted.
• Time worked as a part-time, temporary, or seasonal employee counts toward the requirement.
• An employee returning from fulfilling a USERRA-covered military service obligation is credited with the hours of service that would have been performed but for the period of military service. The employee’s pre-service work schedule can generally be used for calculations to determine hours that would have been worked during the period of military service.

The forms listed below are now required so that we may determine if any related absences may be designated as FMLA leave. Failure to submit the required completed and signed forms may delay or prevent leave approval. 

1. FMLA Request Form

Please complete and submit this form thirty (30) days prior to your requested leave OR as soon as practicable if your leave is of an unplanned, emergency nature. This form must also include your Department Head’s signature acknowledging that they were informed of the request for leave and verify your accrued leave balances, if applicable.

2. FMLA Insurance Disclosure Agreement

This form must be completed to avoid any issues related to your insurance coverage. A completed and signed form is required, even if you do not participate in any City insurance programs.

3. Certification of Health Care Provider for Employee and/or Family Member’s Serious Health Condition

This certification form must be given to your physician (or to your eligible family member’s physician) for completion. Your physician shall submit the completed forms directly to the Human Resources Director via fax, email or US Mail.

4. Return to Work Certification

This form must be completed by you and your physician. Your physician shall submit the completed forms directly to Human Resources via fax, email or US Mail no later than three to five (3-5) business days prior to your return to work. This form is NOT required if you are on FMLA leave for a family member.

 Below are the Certification Forms relative to the requested leave which must be completed and faxed directly to Human Resources:

WH-380E        Employees Serious Health Condition

WH-380F        Family Members Serious Health Condition

WH-384          Certification for Military Family Medical Leave

WH-385          Certification for Serious Injury or Illness of a Current Service Member

WH-385-V      Certification for Serious Injury or Illness of a Veteran

Certification of Adoption or Foster Care Placement

All forms should be completed and returned directly to Human Resources within 30 (thirty) calendar days of the first day of your leave with the exception of the Health Care Provider Form which is to be returned at least fifteen (15) calendar days upon receipt. 

Failure to provide the required documentation in a timely manner may result in delay or denial of requested leave.

Fact Sheet #28D Employee Notification Requirements under the Family Medical Leave Act

FMLA Poster

City of Brockton FMLA Policy

Court Leave (Jury Duty)

Eligible employees may receive regular salary when called to serve for jury duty or act as a witness on behalf of a governmental body. The appropriate court document and/or jury duty notice must be submitted to the Human Resources Department.

Military Leave

Paid military leave is granted to eligible employees called to duty in the armed forces of the commonwealth in the event of natural disaster or civil disturbance; unpaid leave for extended periods of active duty. Please see FMLA for Military Family Leave.

Bereavement Leave

Eligible employees may take bereavement leave depending on the relationship to the deceased.  Please see your respective Collective Bargaining Agreement or Code of Ordinances (Sec. 2-136. - Funeral leave).