McDonald s Leave Of Absence Form Instructions

Transcription

1 McDonald s Leave Of Absence Form Instructions The following outlines the procedures for requesting time off for Medical Leave Without Pay, Family Leave, Personal Leave, Military Leave, or paid Adoption Leave. YOUR REQUEST CANNOT BE PROCESSED UNTIL YOU SUBMIT THE COMPLETED LEAVE OF ABSENCE APPLICATION FORM. The following instructions will assist you in completing the form and forwarding it properly. IF YOU NEED ASSISTANCE FILLING OUT THIS FORM Contact McDonald s Service Center at or your local Human Resources Department. For additional information regarding Leave of Absence, see McDonald s Policies and Programs Total Compensation Handbook and McDonald s Policies and Programs Total Compensation Manual. Requests for a Medical Leave of Absence Without Pay or leave for certain family reasons, including paid Adoption Leave or a leave due to a work-related disability, may also qualify as a request for a Family and Medical Leave depending upon your eligibility. If your request does in fact qualify for a Family and Medical Leave, such leave will run concurrently with your requested leave. In order for your request to be processed appropriately, it is important that you understand your rights and responsibilities. Refer to the enclosed Family and Medical Leave Rights and Responsibilities sheet, which contains information regarding your rights under the Family and Medical Leave Act of SHORT TERM DISABILITY: If you are requesting a leave of absence under our Short Term Disability (STD) Program, please refer to the Short Term Disability Form and Instructions, which can be requested through the McDonald s Service Center Fax-Back System. The Fax-Back System can be reached by calling the Service Center toll-free at The Form # is The form is also available on the McDonald s intranet. PAID ADOPTION LEAVE / PERSONAL LEAVE / MILITARY LEAVE / FAMILY LEAVE (Due to the birth of a baby or adoption): Complete the McDonald s Leave of Absence Form included in this information. After reading the McDonald s Leave of Absence-Important Insurance sheet on page 3, sign and date the form. If you are requesting a Paid Adoption Leave, attach a copy of the adoption papers or the final placement agreement to the Leave of Absence Form. Send the Leave of Absence Form to the Service Center after you retain a copy for your file. FAMILY LEAVE (For the serious health condition of employee or eligible family member) / MEDICAL LEAVE WITHOUT PAY: Complete the McDonald s Leave of Absence Form included in this information. After reading the McDonald s Leave of Absence-Important Insurance sheet on page 3, sign and date the form. If a Family Leave is being requested to care for the serious health condition of an eligible family member or your own serious health condition, the Medical Condition Form must be completed. A copy of the Medical Condition Form is included in this packet. You may also be required to provide periodic medical information (at your expense) to the company or its consultants concerning your condition of that of your family member. The employee completes the top section. The patient must complete their section and review and sign the authorization of information. Once the authorization section is signed, the patient should give the form to the Attending Physician for them to complete. The Physician should retain a copy for their file and return the completed form to the patient. Once the form is complete, the employee should return the Medical Condition Form and the Leave of Absence form to the Service Center. Retain a copy of both forms for your records. MedEval, a medical consulting group, will review the form, contact your physician s office, recommend approval or denial of the application, and determine the appropriate leave length, if approved. McDonald s reserves the right of final approval on all requests. The Service Center will notify you of your leave request status and you will receive a letter with information about the costs and procedures for continuing your insurance. At the end of your leave, the Return to Work Form, included in this packet, should be completed by your physician if the leave was due to your own serious medical condition. This release should be given to your immediate supervisor or your local Human Resources department. You will not be allowed to return to active work until it is received. This leave of absence form is for administrative purposes only and does not constitute a contract of employment.

2 McDonald s Leave of Absence Important Insurance This form contains important information surrounding a Leave of Absence. You can find additional information on the Instruction Sheet and Form for your particular leave. These documents are available through the McDonald s Service Center by calling toll-free at IF YOU HAVE ANY QUESTIONS REGARDING THIS INFORMATION Contact McDonald s Service Center at or your local Human Resources Department. For additional information regarding Leave of Absence, see McDonald s Policies and Programs Total Compensation Handbook and McDonald s Policies and Programs Total Compensation Manual. Medical Leave Without Pay, Family Leave: To continue Medical/Dental/Life Insurance and Healthcare FSA you must have been covered by the benefit immediately prior to the Leave Of Absence. You may continue Medical/Dental/Life Insurance for the duration of the leave at the employee premium cost. You must pay the appropriate contribution during the leave period for your insurance and your healthcare FSA, otherwise coverage may be discontinued. Maximum duration is: Medical Leave Without Pay to a maximum of 30 months from the date of disability; Family Leave (FMLA) to a maximum of 12 weeks (state law may vary); Paid Adoption Leave to a maximum of 4 weeks (deductions will continue to be taken from your paycheck for Adoption Leave). You may continue Medical/Dental/Life Insurance and Healthcare FSA for part or all of the leave period; however, if insurance and/or FSA is not continued at the onset of the leave, you may not start up coverage later during your Leave of Absence. If you wish to continue your benefits/insurance coverage, you need to make the appropriate elections on the Leave of Absence Form. Contact the Service Center for the exact premium amounts. Payments should be made to McDonald's Corporation and sent to the Service Center address listed at the bottom of the Leave of Absence Form. Premium payments should be submitted on a bi-weekly basis. The bi-weekly payments are due on the regularly scheduled McDonald s payday. As an option, you may choose for your convenience, to submit payment for the entire leave period in advance. This is not required by McDonald s. If you are electing this voluntary option, please indicate this in writing when you submit your payment. If your Leave of Absence is extended, you must continue to make premium/contribution payments during the extension period; otherwise your insurance/fsa may be discontinued for the leave period. Military and Personal Leave of Absence: If you were covered by Medical/Dental Insurance and Healthcare FSA immediately prior to the Leave of Absence, you will be offered the opportunity to continue these coverage s through COBRA. A separate letter(s) will be sent to you offering COBRA coverage. Your Medical/Dental Insurance cost is the employee premium and McDonald s share of the premium, plus a 2% administration fee. Your Healthcare FSA cost will remain at your current election amount. If you were covered by Life Insurance immediately prior to the Leave of Absence, your Life Insurance ends the last day of the month when you go on your leave. You may, however, convert your Life Insurance (Basic, Optional, and/or Universal Life and Dependent) to an individual policy with MetLife. This is your responsibility and your expense. To convert or get details and costs, call MetLife at MetLife. If Medical/Dental/Life Insurance and Healthcare FSA are not continued during a Leave of Absence (as described above): Upon return to work, you will have to satisfy the same Medical/Dental/Life Insurance eligibility requirements (i.e., waiting period, pre-existing conditions, etc.) as a new employee. You will be ineligible to participate in Healthcare FSA until the following January 1 st. (Eligibility requirements waived for FMLA and Military Leaves. Coverage will begin first of the following month.) If you do not return to active employment, you will not be eligible to continue Medical/Dental Insurance or Healthcare FSA under COBRA, or convert Life Insurance to an individual policy. (Restrictions waived for FMLA and Military Leaves.) The Leave of Absence Form is for administrative purposes only and does not constitute a contract of employment.

3 Family and Medical Leave Rights and Responsibilities Under the McDonald s Family and Medical Leave Policy and consistent with the Federal Family and Medical Leave Act (FMLA) and applicable state law rules, you may qualify for up to 12 weeks of unpaid Family Leave within a 12-month period (Calculation Period) for: 1. The birth of your child, or the placement of a child with you for adoption or foster care; or 2. The serious health condition that makes you unable to perform one or more of the essential functions of your job; or 3. A serious health condition affecting your spouse, child or parent, for which you are needed to provide care. The 12-month period (Calculation Period) is measured from the last date you used Family Leave. This means that for each employee, the 12-month period is a rolling period that is not based on the calendar year. When you return to work from a Family Leave of Absence, you will be placed into your previous position or another equivalent position without any reduction of pay, benefits, or other terms of employment. Failure to return to work at the end of the approved leave period may result in the forfeiture of your right to return to your previous position or another position. Additionally, unless the failure to return to work is due to circumstances beyond your control, you may be required to repay McDonald s portion of any health insurance premiums paid during your leave. Please keep in mind the following information: 1. If you do not provide medical certification of a serious health condition within 15 days after you are notified of this requirement, such failure may delay the commencement of your leave until the certification is submitted; 2. You may be required, but may not elect, to substitute accrued paid leave for unpaid FMLA leave; 3. If you currently pay a portion of the premiums for your health insurance, you are responsible for making these payments during the period of FMLA Leave. Arrangements for payment will be communicated to you and you will make premium payments accordingly. You have a 30-day grace period in which to make premium payments. If payment is not made timely, your group health insurance my be canceled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse. We will not pay your share of health insurance premiums while you are on leave; 4. You will be required to present a written healthcare provider s approval prior to being restored to employment (a Return to Work Form is included in this packet for your convenience). If such certification is required but not received, your return to work may be delayed until the certification is provided; 5. While on leave, you will be required to furnish us with reports about your situation and intent to return to work periodically. If the circumstances of your leave change and you are able to return to work full or part-time earlier than the date you have indicated, you are required to notify us at least two work days prior to the date you intend to report to work; 6. You may be required to furnish additionally medical information relating to a serious health condition; 7. If we have agreed to the use of an intermittent or reduced leave schedule, you understand that your pay will be reduced accordingly to reflect the hours actually worked. Please forward this completed form and all required attachments (if applicable) to: FORM /15/06 McDonald s Service Center Dept. 238, McDonald s Corporation, 2111 McDonald s Drive, Oak Brook, IL, Telephone #: (877) Fax #: (630) address: mc.service_center@us.mcd.com

4 Leave of Absence Form/ Extension Form Employee Request Type: THIS IS AN INITIAL REQUEST THIS IS AN EXTENSION REQUEST Last First Middle NAME: EMPLOYEE #: STREET: UNIT: CITY: STATE: ZIP CODE: HOME TELEPHONE#: ( ) - WORK TELEPHONE#: ( ) - DEPT. NAME/ NAT L STORE#: POSITION (Check one): HOME OFFICE STAFF STORE MGMT. PRIMARY MAINT. DIVISION /REGION STAFF CERTIFIED SWING WHAT IS YOUR ACTUAL/ANTICIPATED LAST DAY WORKED? DATE OF BIRTH: HAVE YOU RETURNED TO WORK? YES Date NO REGION #: IMMEDIATE SUPERVISOR (NAME): PHONE: ( ) - Leave Request I am applying for the following leave (Check one): Medical leave without pay Family Leave due to family member s Personal Leave Family Leave due to the birth of a child serious medical condition Adoption Leave for the purpose of Family Leave due to own serious medical condition Military Leave caring for a newly adopted minor child ANTICIPATED DATES FOR LEAVE OF ABSENCE: FROM: THROUGH: Continuation of Insurance Coverage Ins. Election (FMLA and Medical Leave Without Pay) FAMILY AND MEDICAL LEAVE (FMLA)/MEDICAL LEAVE WITHOUT PAY: I understand that I can continue my group insurance by submitting my share of the premium. I understand that if I fail to submit the appropriate premium when my payment is due, my insurance coverage will be terminated. If I am on a FMLA leave, I understand that I have a 30 day grace period in which to make premium payments, and that I will be notified in writing at least 15 days before the date my health coverage will lapse. If I am on a Family or Medical Leave (FMLA), I understand that if I do not return to work, I will be asked to reimburse McDonald s for the employer portion of the premium which was paid on my behalf while on this leave. PAID ADOPTION LEAVE: I wish to apply for Paid Adoption Leave for the adoption of and certify that I am the person primarily responsible for the care and nurturing of the newly adopted minor child and the Paid Leave will be used for such purposed. Date this child was placed in my home was:. My child s birth date is. I have attached a copy of the adoption papers or the final placement agreement which indicates the child s name and the date the child was placed in my home. I understand that if I am approved for Adoption Leave, my regular insurance premiums will continue to be deducted from my paycheck. I also understand that if I terminate my employment for any reason or change to an ineligible class within 6 months of the expiration of the paid Adoption Leave, I agree to reimburse the Company for the Paid Leave salary paid to me during the Paid Adoption Leave. In addition, any payments made to me in excess of the McDonald s Paid Leave will be reimbursed by me to McDonald s. In either case, I authorize the Company to make such deductions from any money payable to me. PERSONAL/MILITARY LEAVE: I understand that I can continue my medical/dental/healthcare FSA coverage through COBRA at my expense. I understand that I will be sent a separate enrollment form. I understand that my life insurance can be converted to a Met Life individual plan at my expense by calling MET-LIFE. RETURN TO WORK: I understand that if I am on a FMLA leave, when I return to work, I will be placed in my previous position or an equivalent position without any reduction of pay, benefits, or other terms of employment. If I am on a non-fmla leave, I understand that when I return to work, a reasonable effort will be made to place me in the position I held prior to my leave of absence, and that if that position is not available, a reasonable effort will be made to place me in a comparable position at the same rate of pay. I also understand the Personal Leaves of Absence are granted at the sole discretion of McDonald s. If I am taking a Personal Leave that does not qualify for FMLA leave, and if there is no equivalent position available within my department within a reasonable period of time at the end of the approved leave, I understand that my employment may be terminated. I may, however, request to be considered for positions that become available in the future. If my leave qualifies as an FMLA leave, I understand my rights and responsibilities as explained to me on page 2 of this packet. I have read and understand the information stated above and the McDonald s Leave of Absence Important sheet included in this packet. I understand I need to contact McDonald s Service Center to obtain information on my exact premium amounts. If I elect to continue any of these benefits, I understand that I need to submit my premium to McDonald s Corporation timely. After reviewing this information I choose to continue the following insurance/ benefits: MEDICAL PLAN DENTAL PLAN HEALTHCARE FSA OPTIONAL TERM LIFE DEPENDENT OPTIONAL TERM LIFE UNIVERSAL LIFE-OPTIONAL UNIVERSAL LIFE-ACCUMULATION ACCT. I DO NOT WISH TO CONTINUE INSURANCE Employee Signature I am requesting a Leave of Absence as described above and I have read and understand this information. I further understand that if my requested leave also qualifies as Family and Medical Leave, then Family and Medical Leave will run concurrently with my requested leave. Signature: Date: Please forward this completed form and all required attachments (if applicable) to: FORM /15/06 McDonald s Service Center Dept. 238, McDonald s Corporation, 2111 McDonald s Drive, Oak Brook, IL, Telephone #: (877) Fax #: (630) address: mc.service_center@us.mcd.com

5 McDonald s Medical Condition Form Instructions The following form must be completed if you are applying for a Medical Leave of Absence Without Pay or a Family Leave due to your own serious medical condition or the serious medical condition of a qualified immediate family member. YOUR REQUEST CANNOT BE PROCESSED UNTIL YOU SUBMIT THE COMPLETED MEDICAL CONDITION FORM AND THE COMPLETED LEAVE OF ABSENCE APPLICATION FORM. The following instructions will assist you in completing the Medical Condition Form. IF YOU NEED ASSISTANCE FILLING OUT THIS FORM Contact McDonald s Service Center at or your local Human Resources Department. For additional information regarding Leave of Absence, see McDonald s Policies and Programs Total Compensation Handbook and McDonald s Policies and Programs Total Compensation Manual. In order to be approved for a Medical Leave of Absence Without Pay or a Family Leave due to a serious medical condition, you will be required to provide medical condition information on yourself or the family member you will be caring for. You may also be required to provide periodic updated medical information (at your expense) to the Company or its consultants concerning your condition or that of your family member. Please use the Medical Condition Form to provide this information. An additional copy of the Medical Condition Form is available through the McDonald s Service Center Fax-Back system, which can be accessed by calling toll-free The form number is The form is also available on the McDonald s intranet. The employee should complete the Employee section. The patient (or the patient s legal guardian) then completes both the Patient and Authorization sections. Once the Authorization section is signed, the patient (or the patient s legal guardian) should give the form to the Attending Physician for completion. The Physician should retain a copy for their file and return the completed form to the patient (or the patient s legal guardian). Once the form is complete, the employee should return the Medical Condition Form and the McDonald s Leave of Absence Application Form to the Service Center. Retain a copy of both forms for your records. MedEval, a medical consulting group, will review all forms, contact your physician s office, recommend approval or denial, and determine the appropriate leave length, if the leave is approved. McDonald s reserves the right of final approval on all requests. The Service Center will notify you of your leave request status.

6 Medical Condition Form Employee Patient Patient Authorization All blanks must be completed to process your request. Return this form to the Service Center upon completion by physician. Last First Middle NAME: EMPLOYEE #: HOME TELEPHONE#: ( ) - WORK TELEPHONE#: ( ) - POSITION (Check one): HOME OFFICE STAFF STORE MGMT. PRIMARY MAINT. DIVISION /REGION STAFF CERTIFIED SWING Last First Middle NAME: SSN: - - RELATIONSHIP TO EMPLOYEE: DATE OF BIRTH: ADDRESS STREET: CITY: STATE: ZIP: I hereby authorize the undersigned healthcare provider to release to McDonald s Corporation and/or MedEval Corporation any and all information which they possess which is pertinent to my medical condition. I authorize MedEval Corporation to disclose to McDonald s Corporation any and all information pertinent to my medical condition or otherwise which Med Eval Corporation may receive from the undersigned healthcare provider. PATIENT OR GUARDIAN S SIGNATURE: DATE: Attending Physician Please complete all applicable sections and please be specific. Retain photocopy for your files and return completed form to patient. Medical facts supporting absence: If pregnancy, anticipated date of delivery (EDC): If no, complications: Dates of services: Treatment: Normal to date? Yes No Dates of hospitalization/ Expected hospitalization: Expected date of recovery: Is patient continuously and totally incapacitated? Yes No If yes, date: If patient will need care only intermittently or on a part-time basis, please indicate the probable duration of this need: If patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide estimate of probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any: Does patient require assistance for basic medical or personal needs, safety, or for transportation? Yes No Period/dates during which employee s presence is necessary to provide assistance: PHYSICIAN S NAME (PRINT): DEGREE: ADDRESS STREET: CITY: STATE: ZIP: TELEPHONE#: ( ) OFFICE CONTACT: PHYSICIAN S SIGNATURE: DATE: Please forward this completed form and all required attachments (if applicable) to: FORM /15/06 McDonald s Service Center Dept. 238, McDonald s Corporation, 2111 McDonald s Drive, Oak Brook, IL, Telephone #: (877) Fax #: (630) address: mc.service_center@us.mcd.com

7 McDonald s Return to Work Form Instructions If you have been out on leave due to your own medical condition, you must have an authorized Return to Work Form before you will be allowed to come back to work. The following instructions will assist you in completing the form and forwarding it properly. IF YOU NEED ASSISTANCE FILLING OUT THIS FORM Contact McDonald s Service Center at or your local Human Resources Department. For additional information regarding Leave of Absence, see McDonald s Policies and Programs Total Compensation Handbook and McDonald s Policies and Programs Total Compensation Manual. If you are returning to work after an absence due to your own medical condition, you must complete the McDonald s Return to Work Form. An additional copy of this form is available through the McDonald s Service Center Fax-Back system, which can be accessed by calling toll-free The Form number is The form is also available on the McDonald s intranet. Complete the Employee section at the top of the form. After reading the Employee Authorization section, sign and date the form. Give the signed form to your physician and have them complete the Attending Physician. The physician should retain a copy for their records and return the completed form to you. Provide the completed form to your immediate supervisor or your local Human Resources Department. After they receive this form, they will discuss your return to work information with you. This leave of absence form is for administrative purposes only and does not constitute a contract of employment.

8 Return to Work Form Employee Last First Middle NAME: EMPLOYEE #: REGION#: DIVISION#: HOME OFFICE DEPARTMENT#: NATIONAL STORE#: HOME TELEPHONE#: ( ) - WORK TELEPHONE#: ( ) - Patient Authorization POSITION (Check one): STAFF STORE MGMT.. CERTIFIED SWING PRIMARY MAINT. I hereby authorize the undersigned healthcare provider to release to McDonald s Corporation and/or MedEval Corporation any and all information which he/she possesses which is pertinent to my medical condition. I authorize MedEval Corporation to disclose to McDonald s Corporation any and all information pertinent to my medical condition or otherwise, which MedEval Corporation may receive from the undersigned healthcare provider. PATIENT OR GUARDIAN S SIGNATURE: DATE: Attending Physician Please complete all applicable sections and please be specific. Retain photocopy for your files and return completed form to patient. Treated for: May resume work as of (date) with no limitations. May resume work as of (date) with the following limitations (check appropriate condition): Sedentary work Involves sitting, occasional walking, standing, i.e., typing, answering phones, working Drive-Thru booth, cashier, managing a shift (directing employees, making decisions). Light work Lifting 20 lbs. Maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs. A small degree of pushing and pulling of arm and/or leg controls, or when it requires walking or standing to a significant degree. Medium work Lifting 50 lbs. Maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs. Heavy work Lifting 100 lbs. Maximum with frequent lifting and/or carrying of objects up to 50 lbs. # Hours per day: How long at modified work? Return for treatment on: Estimated date of return to work without restrictions: PHYSICIAN S NAME (PRINT): DEGREE: ADDRESS STREET: CITY: STATE: ZIP: TELEPHONE#: ( ) OFFICE CONTACT: PHYSICIAN S SIGNATURE: DATE: Please forward this completed form and all required attachments (if applicable) to: FORM /15/06 McDonald s Service Center Dept. 238, McDonald s Corporation, 2111 McDonald s Drive, Oak Brook, IL, Telephone #: (877) Fax #: (630) address: mc.service_center@us.mcd.com