b'Maintain Key Records for New Times Track and Manage FMLA Requests Employee Certification ComplyRight Electronic Formatto Return to Work Certification to Return to Work Form ComplyRightComplete this self-certification form prior to your return to work if you: (1) have had symptoms of COVID-19;2021 Gradience FMLA Tracker(2) have had close contact with an individual diagnosed or showing symptoms of COVID-19; or (3) have beenTake proactive measures to prevent the spread of directed to self-isolate or quarantine by your healthcare provider or a public health official.Upon completion, return the form to your human resources manager or supervisor as directed. You may beillness in the workplace. In compliance with theEliminate the hassle of manually managing employee asked to provide supporting documentation. Failure to properly complete and submit the form may prevent you from returning to work. Americans with Disabilities Act, this form requirestime-off requests under the Family and Medical Employee Informationaffected employees to acknowledge that theirLeave Act. Just enter basic information and print Name: ________________________________________________ Employee ID #_________________________________________condition has improved, symptoms have subsided,accurate, legally compliant forms for processing Department: ___________________________________________ Job Title: _____________________________________________Todays Date:______________Hire Date:______________ Supervisor: ___________________________________________ and they are released by their healthcare provideryour FMLA leave requests.// //Status: Full-Time Part-Time TemporaryEmployee Self-Certificationto return to work. Includes a Tip Sheet covering I, ____________________________________________, hereby certify that ALL of the following statements are true and accurate: compliance guidelines and recommended bestCalculates available FMLA time based on1 I have had no fever for at least three days (72 hours) without taking fever-reducing medication.federal regulations and your companys policies// practices from our HR and legal teams.Date of last fever of 100.4F or higher:______________2 At least 10 days have passed since my fever and/or respiratory symptoms began. Date fever and/or respiratory symptoms began: ______________ Helps easily track intermittent and//3 If applicable, my respiratory symptoms (cough and shortness of breath) have improved.DescriptionItem #Price long-term employee leaves//Date when respiratory symptoms began improving: ______________4 In the past 10 days, I have not been in close contact with anyone exhibiting COVID-19 symptoms or testing positive for the virus.5 I am not subject to a directive to self-isolate or quarantine by a healthcare provider or a public health official.Standard Form (pkg/50)DL1-A0107$44.99 Includes all mandatory FMLA formsI understand that if I experience a re-emergence of COVID19 symptoms (e.g., fever, cough, or shortness of breath), I must follow isolation guidelines and inform management immediately. (Please refer to the CDCs website for a list of COVID-related symptoms and any updates to this guidance.) // DownloadableDL1-A0107DL$32.99 Includes SmartUpdate by ComplyRight Includes:Date of Requested Return to Work:______________Employee Signature Fill-N-SaveDL1-A0107DL$42.99 to automatically alert you when your softwareCompany ResponsesI certify and attest that the above information is true and accurate to the best of my knowledge. I understand that misrepresentationSize: 8" x 11"of any of this information may prevent me from returning to work, as well as subject me to discipline up to and including termination. needs an update to stay current with newEmployee Leave Request Employee signature:___________________________________________________________________ Date:_________________ government guidelines, rules or laws// Downloadable and Mandatory Employee NoticeEMPLOYER: Treat this form as a medical record, keeping it separate from employee personnel files and only allowing access to designated personnel. Fill-N-Save item Medical Certification (Employee)o ation. However, it is not a substitute for legal advice and does ncorte aptrionvgi,d per loedguacl ingItem #PriceThis product is designed to provideer vacicceusr. aTteh ea nindf aorumthaotriiotnat iisv ep rinovfoidrme odfwthieth u tshee o ur nindaebrsiltiatny dtoin ugs teh taht ias npyr opdeurscot.n Y ooru e anrtei tuy rignevdo ltvoe cdo inns ult an attorneyorp idniisotrnisb uotni nang yth sipse pcirfoidc ufactc tissonro sti olina balne dfo arn ayn syp decaimficag qeuse asrtiisoinnsgooru ctoncerns you may have.A20102007 DCLom_FpilllynRSigahvte, Inc. conpcoerrtnainntg n yooteu:r T pharist iicsu alpapr rsoitvueadt for use by the purchaser only. This form may not be shared publicly or with third parties. Medical Certification (Exigency)Im DL1-S1072$619Call for details on multi-site licenses. Medical Certification (Family Member)Requires annual renewal to stay compliant.Medical Certification (Injury/Illness)System requirements shown on page 12. Try it FREE for 30 days; call for detailsRemote Work Request Paper & Downloadable Formats ComplyRight Employee Information Remote Work Request Form Name: __________________________________________________________Position: _____________________________________ ComplyRightI.D.#: _______________________Department: ________________________Supervisor: __________________________________ FMLA Administration System tary Certification MLA Leave// // Medlyi cMale Cmebrteirfi)cationM(Eilixtiagreyn Ccey)rtification (InjuMryi/liillness)(Form H1 and H2) TrFacker(Forms I) Medical Certification Simplify and standardize the request-and- Hire Date:___________________Date of Request:_____________________ (Fami (Forms F) (Form G) Company Response (Employee)(Form E)ManNdoattoEmployee Employee FMLA Coesmigpnaantyio Rne)sponseicreyReason(s) for Request Heres everything you need to effectively(Form A) Leave Requests(Form B) (Eligibility)(Form C) (D (Form D)approval process for employees asking to workI would like to work remotely as follows:I am requesting to work remotely on the following dates (indicate specific dates and/or date range(s), if applicable): manage FMLA requests. With clear instructions remotely. The form requires employees to_______________________________________________________________________________________________________document requests and provide details regarding_______________________________________________________________________________________________________ and easy-to-use forms, the system simplifiesI am requesting to work remotely on an ongoing basis, as follows (indicate number of days per week and other details as applicable): your FMLA responsibilities. the duration, extenuating circumstances and______________________________________________________________________________________________________________________________________________________________________________________________________________more. Includes a Tip Sheet covering compliancePlease describe how you think your job responsibilities are suited for working remotely:_____________________________________________________________________________________________________________ Includes all the forms you need to manageguidelines and recommended best practices from_____________________________________________________________________________________________________________ FMLA requestsI have discussed working remotely with my supervisor and understand that my request does not guarantee that I will automatically be our HR and legal teams. eligible. I have read the Companys policy on telecommuting and/or remote work, and understand that it is not appropriate for every employee or job position. I understand that the ability to work remotely can be terminated at any time by the Company. Tabbed-divider folder keeps forms organized//Employees Signature: ________________________________________________________________Date: __________________DescriptionItem #Price Manager/Supervisor Approval Flow chart walks you through the stepsBy signing below, I acknowledge that I have discussed the possibility of working remotely with the above-named employee, and that I believe this employee is an appropriate candidate for working remotely based on his/her job responsibilities and performance in his/heryou need to keep in complianceStandard Form (pkg/50)DL1-A0147$44.99 current role or position.//Supervisors Signature: _______________________________________________________________Date: __________________DownloadableDL1-A0147DL$32.99For Office Use Only DescriptionItem #PriceFill-N-SaveDL1-A0147DL$42.99 APPROVED Provide Details:________________________________________________________________________________ ________________________________________________________________________________ Administration SystemDL1-A1441$145Size: 8" x 11" DENIED Reason:Job position and/or specific responsibilities not suitable for remote work at this timeOther: _____________________________________________________________________________ DownloadableDL1-A1441DL$145Downloadable and Supervisor/HR Managers Name: ___________________________________________________________________________________Supervisor/HR Managers Signature:_____________________________________________________Date: _________________ Fill-N-SaveDL1-A1441DL$145//Fill-N-Save item This prod ounc ta insy d sepseigcnifeicdftaoc ptsr oovr isdeer vacicceusr. aTteh ea nindf aourmthaotrioitnat iisv ep rinovfoidrmeda twioitnh.tHhoe wuenvdeerr, sitt ains dniontg a t hsuabt satnityu ptee rfosor nle ogra le andtivtiyc ien avnodlv dedo eisn n corte aptrionvgi,d per loedguacl ingForms Refill PackDL1-A1433$109 FMLA Administration System Includes: opinionsbnugt iynogu trh pisa rptriocduulacrtsiist unaotti olina balne dfo arn ayn syp decaimfica gqeus easrtiiosinnsg o oru cto onf ctehren us syeo uor m inaayb hilaivtye .to use this product. You are urged to consult an attorney A20102407 DCoLm_FpillylnRSigahvte, Inc. o trniint note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.cor ndciesrtaImpor Forms Refill Pack includes all forms, plus FMLA LeaveOrganizer with FMLA Flow Chart (1)Tracker (10). Size: 8" x 11" or 17" x 11"FMLA Leave Tracker (10) Downloadable and Complete set of forms and certifications See the entire collection of COVID-19 resources at hrdirect.com/COVID Fill-N-Save item (10 of each)14 WORKPLACE MANAGEMENTRECORDKEEPING HRDIRECT.COM800.999.9111 15'