Form 16873 – Fill Out and Use This PDF

FORM 16873

REV. 4/8/13

Union Pacific Railroad

Notice of Eligibility and Rights & Responsibilities

Family and Medical Leave Act (including Family Military Leave)

Employee:				Agreement /			Non Agreement
Employee ID #:				Service Unit:
Job Title:				Supervisor:

UPON AN EMPLOYEE’S REQUEST FOR FMLA LEAVE, THIS FORM MUST BE COMPLETED AND PROVIDED TO THE EMPLOYEE BY THE EMPLOYEE’S SUPERVISOR OR THE DESIGNATED STAFF OF THE EMPLOYEE’S SUPERVISING DEPARTMENT.

In general, to be eligible for FMLA leave an employee must have worked for an employer for at least 12 months and have worked at least 1,250 hours in the 12 months preceding the leave.

On (date)	, you informed us that you needed A ONE TIME CONTINUOUS BLOCK OF LEAVE or
INTERMITTENT TIME OFF beginning on				through approximately		for:

The birth of a child, or the placement of a child with you for adoption or foster care.

Estimated date of birth or placement of child. (Note that leave for bonding

with a newborn or newly placed child must be completed within one year of the child’s birth or placement; and such leave may not be taken intermittently following the birth or placement and may only be taken in one continuous block of leave.); or

Your own serious health condition
Because you are needed to care for your	spouse,	child (age	),		parent
due to his/her serious health condition.

Spouse - means a husband, wife or civil union partner as defined or recognized under State law for purposes of marriage in the State where the employee resides, including common law marriage in States where it is recognized.

Child - means a biological, adopted, or foster child, a stepchild, a legal ward, or a child of a person standing in loco parentis, who is either under age 18, or age 18 or older and “incapable of self-care because of a mental or physical disability” at the time that FMLA leave is to commence. (See § 825.122 of the DOL Electronic Code of Federal Regulations for the definition of incapable of self care)

Parent - means a biological, adoptive, step or foster father or mother, or any other individual who stood in loco parentis to the employee when the employee was a son or daughter as defined in paragraph (d) of this section. This term does not include parents “in law.”

Because of a qualifying exigency arising out of the fact that your

spouse,

parent, or

child

is either

1)a member of the National Guard and/or Reserves and has been called to active duty status in support of a national emergency, or a military action or operation outside the U.S. or

2)a member of the regular Armed Forces who is or has been deployed to an assignment outside the U.S.

Because you are the spouse, son or daughter, parent, next of kin of a covered service member with a serious injury or illness.

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FORM 16873

REV. 4/8/13

This is to inform you that:

1. You	meet /		do not meet the 12 months of total service and 1250 actual hours worked.
Date of Hire:				Approximate Hours Worked:

2.In order for us to determine whether your absence qualifies as FMLA leave, you must return the following information to the Health & Medical Services Department within 15 days of the date of this form.

Certification Form 16874 - for Employee’s Own or Family Member’s Serious Health Condition.

Certification Form 16876 - for Qualifying Exigency - for Military Family Leave

Certification Form 16877 - Serious Injury or Illness of Covered Servicemember - for Military Family Leave.

Other documentation to verify the birth of a child or placement of a child for adoption or foster care.

Union Pacific Health and Medical Services Department

1400 Douglas Street, Stop 0350

Omaha, NE 68179

Fax: (402) 233-3305

Please note that forms that are not filled in completely or provide vague responses will be returned.

3.You are conditionally approved to use FMLA during the certification process. If certification is not provided or does not substantiate your eligibility for leave as defined by the FMLA, any absences taken under FMLA will not be protected, and may be subject to discipline as unexcused absences.

4.This leave will be counted against your annual FMLA leave entitlement. Employees have 12 workweeks or the equivalent of 12 workweeks of FMLA leave available on an annual basis.

5.(A) Agreement Employees:

You may choose to take accrued paid leave time (vacation or personal leave) concurrent with FMLA leave (or you may be required to do so depending on your local agreement). You are required to substitute accrued sick leave, if applicable, for your own serious health condition.

Employees receiving sickness benefits from Railroad Retirement, or employees receiving Supplemental Sickness Benefits (SSB) under the National Health and Welfare Plans while on leave will not be allowed to use other accrued paid leave, but such leave will count against the 12 weeks of leave allowed under FMLA.

In order to use paid leave for FMLA leave, employees must comply with Union Pacific’s normal paid leave policies and follow your department’s procedures for requesting such paid leave.

(B) Non-agreement Employees:

Short Term Disability days will be charged against any FMLA leave entitlement for your own serious health condition except FMLA leave taken in connection with the birth of an employee’s child.

You may elect to use any available vacation while on FMLA leave other than for your own serious health condition. In order to use paid leave concurrently with FMLA leave, employees must comply with Union Pacific’s normal paid leave policies and follow your department’s procedures for requesting such paid leave.

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FORM 16873

REV. 4/8/13

6.If you normally pay a portion of the premiums for your health insurance, you must continue to make these payments during the period of FMLA leave. If you are a Hospital Association member, you must continue your health insurance payments during the period of FMLA leave. You have a 30-day grace period in which to make premium payments. If payment is not made timely, your health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share of the premiums during the FMLA leave, and recover these payments from you upon return to work.

Checks should be made payable to and mailed to:	UNION PACIFIC RAILROAD
	MANAGER PAYROLL ACCOUNTING
	1400 DOUGLAS STREET, Stop 1730
	OMAHA NE 68179

If you have any question regarding health benefits maintenance during FMLA leave, please call the HR Service Center at (877) 275-8747 for non-agreement employees and the General Director of Labor Relations Program Administration at (402) 544-4179 for agreement employees.

7.If taking leave for your own serious health condition, you will be required to present a return to work certificate from your health care provider prior to returning to work. If such certification is not received, your return to work may be delayed until a certification is provided.

IMPORTANT INFORMATION FOR EMPLOYEES:

Qualified employees have a right under the Family & Medical Leave Act for 1993 (FMLA) for up to 12 workweeks of unpaid leave during the calendar year for qualifying reasons; you have a right under the FMLA for up to 26 workweeks of unpaid leave in a calendar year to care for a covered service member with a serious injury or illness. You are to be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from leave as you held before your leave commenced if you are a non-agreement employee, or as provided for in your collective bargaining agreement if you are an agreement employee. If you do not return to work following FMLA leave for a reason other than: (1) the continuation, reoccurrence, or onset of a serious health condition which would entitle you to FMLA leave; (2) the continuation, reoccurrence, or onset of a covered servicemember’s serious injury or illness which would entitle you to FMLA leave; or (3) other circumstances beyond your control, you may be required to reimburse the Company for its share of health insurance premiums paid on your behalf during your FMLA leave. Time taken for any reason that would qualify for FMLA leave will be counted against the 12 workweeks of leave allowed each calendar year, except leave available to a non-agreement employee due to the birth of such employee’s child. If the employer receives objective evidence that casts doubt on the validity of your certification, or your intent to use FMLA other than for its intended purpose, the company reserves the right to investigate and/or pursue disciplinary action.

If you have any questions, contact		or view the FMLA
Policy online at http://home.www.uprr.com/emp/ec/policy/time_away/index.shtml.

FORM COMPLETED

ON:By:

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