IHB LOGO FMLA and Medical Leave Forms and Information

Welcome to the IHB FMLA and Medical Leave information page.

    On this page, you will find information and resources related to the FMLA (Family and Medical Leave Act) and company authorized medical leaves of absence.

    If you need time off for yourself or a qualifying family member for medical reasons, see the FMLA section. The 'Employee Guide to FMLA' explains eligibility, qualifying health conditions and qualifying family members. If you do not qualify for FMLA, you may request a company authorized medical leave of absence, for your own medical condition, which will be granted at the discretion of the IHB. Please see medical leave of absence section below.

    If you have questions regarding any of the information or forms, please contact us at HR@ihbrr.com or 219-989-4923. We will be happy to answer any questions and help you with this process. Below you will find the IHB ‘s FMLA and Medical Leave of Absence Policy, the IHB’s Requesting Off Policy, the Employee’s Guide to FMLA from the Department of Labor, and instructions for T & E employees submitting lay-off requests in the kiosk.

FMLA and Medical Leave of Absence Policy (Eff. 7-30-2018)
Requesting Off Policy (Eff. 07-30-2018)
Employee Guide to FMLA
Instructions for T & E Employees Submitting Lay-off Requests in Kiosk
Non-Agreement Medical Leave Policy


Section I - FMLA (Family and Medical Leave Act)

    This section contains information and forms for applying for a FMLA leave. Eligible employees may be entitled to up to 12 weeks of FMLA leave for a qualifying health condition for themselves or a qualifying family member. For information on eligibility, qualifying conditions and qualifying family members, please see the Employee Guide to FMLA from the Dept. of Labor above. Below you will find the necessary forms needed to apply for an FMLA leave. You may print whichever forms apply to your needs and have them completed and submitted to us. If you are unsure which forms you will need or if you do not have access to a printer and would like the forms mailed to you, you may contact us at any time and we will be happy to assist you.

WH380-E Request FMLA for Employee Health Condition
WH380-F Request FMLA for Family Member Health Condition
WH384 Certification of Qualifying Exigency for Military Family Leave
WH385 Certification of Injury or Illness for Current Servicemember for Military Family Leave
WH385-V Certification of Injury or Illness for Veteran for Military Caregiver Leave
MD-201 Fitness for Duty Certification Form
MD-1000 Prescription Drug Report


Section II - Company Authorized Medical Leave of Absence

    This section contains information and forms for applying for a company authorized medical leave of absence. If an employee is not eligible for FMLA or if they have exhausted all available FMLA but still need time off of work for medical reasons, the IHB may, at their discretion, grant a medical leave of absence.

Medical Leave of Absence Request Form


Section III - ADA (Americans with Disabilities Act)

    This section contains information and forms for applying for an accommodation. The ADA protects disabled employees from discrimination and requires employers to make reasonable accommodations to allow employees with disabilities to do their jobs. If an employee has a disability for which they feel the IHB could make a reasonable accommodation to allow them to perform their job duties, they can make a request for such an accommodation.

Accommodation Request Form
Accommodation Medical Certification