Employee Forms

Personnel Rules

Employee Assistance Program

 

Family Medical Leave Forms

 Employee Rights and Responsibilities under the Family Medical Leave Act

FMLA Poster - Employee Rights

 

 Please select the appropriate form from the choices below.

*NOTE : Unless there has been a medical emergency, these forms should be completed and sent to the City of Middletown Human Resources Division at least 30 days prior to your expected leave; or as soon as the employee is aware of this need. Family medical leave forms should be completed if your period of incapacity is longer than three (3) consecutive calendar days combined with a least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment.

Employees who are expected to be out of work more than three (3) consecutive days dues to a qualifying illness, or who may require intermittent leave due to a qualifying chronic illness, must have their treating physician complete the appropriate Family Medical Leave forms and have them returned to the City of Middletown Human Resources Division.
Employees will receive approval notification once all required medical documentation has been received and eligibility has been determined by the City of Middletown Human Resources Division.

Leave Due to An Employee's Serious Health Condition

Please contact the City of Middletown Human Resources Division for a copy of your job description. Your job description should be attached to this form before submitting it to your treating physician.

WH-380-Employee Leave

Leave Due to a Qualifying Family Members Serious Health Condition

WH-380-Family Member Leave

Certification of Qualifying Exigency for Military Family Leave

WH-384 - Cert. of Qualifying Exigency for Military Family Leave

Certification for Serious Injury or Illness of a Current Service Member - for Military Family Leave

WH-385 - Cert. for Serious Injury or Illness of a Current Service Member - for Military Family Leave

Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave

WH-385V - Cert. for Serious Injury or Illness of a Veteran for Military Caregiver Leave

   

For more information, please visit the Department of Labor Family Medical Leave webpage.

  

If you have any questions, please contact the City of Middletown Human Resources Division at 860-638-4940.