HomeMy WebLinkAboutResolution 95-257 10/02/1995 i_,
~'?S®L.~~~®N 95-257
of the City of Petala, California
1
2 RESOLUTION AMENDING THE CLASSIFICATION PLAN
3 TO ESTABLISH THE POSITION CLASSIFICATION
4 UTILITY ENGINEER
5 DESIGNATED TO UNIT 9, (MID-MANAGEMENT)
6
7
8 BE IT RESOLVED that the Classification Plan and
9 Compensation Plan, as originally adopted pursuant to Resolution
10 No. 90-2D9 N.C.S., and the classification titles and
11 specifications as adopted by Resolution No. 90-147 N.C.S., are
12 hereby amended by establishing the classification of Utility
13 Engineer, ( as attached hereto and marked Exhibit "A" and made a
14 part hereof).
15
16 BE IT FURTHER RESOLVED that this action is taken
17 pursuant to Personnel Code 2.04.020 and Personnel Rules and
18 Regulations (Rule IV, Section 5) for classifications included in
19 the Competitive Service of the Personnel System, that the notice
20 of this action has been properly posted and that the City Manager
21 recommends this action.
22
23 NOW THEREFORE, BE IT RESOLVED that the Resolution No.
24 90-147 N.C.S., as amended, is hereby amended to include
25 establishment of the classification of Utility Engineer and
26 assigning this classification to Unit 9 (Mid-Management),
27 effective October 2, 1995 with a salary range of $4,838 - $5,880.
Under the power and authority conferred upon this Council by the Charter of said City.
REFERENCE: I hereby certify the foregoing Resolution waa introduced and adopted by the Approved as to
Council of the City of Petaluma at a (Regular) (.~:~ped~meeting fO~
on the ..-•---2r~d..---...... day of ............4~tc>b~I 19...5. by the r~
following vote:
City Attorney
AYES: Hamilton, Maguire, Read, Vice Mayor Shea
NOES: None
ABSENT: Sto pe, B r Hilligoss ~
ATTEST : ..............ll..l:~.:
~ y clerk M~YRrx Vice Mayor
Gbtmcil Fiie
CA 1085 Res. No...q~.ir.~rJ. N.C.S.
CITY OF PETALUMA
COMPENSATION PLAN FOR UNIT 9 - (MID-MANAGEMENT)
FY 1995 - 1996
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TABLE OF CONTENTS
GENERAL
Section 1. Term
COIyIPENSATION
Section 2. Salary
Section 3. Compensation For Clothing Loss
Section 4. Vacation, Payment Of
Section 5. Sick Leave, Payment Of
Section 6. Deferred Compensation
Section 7. PERS Employer Paid Contribution
Section 8. Work During A Local Emergency
Section 9. Retiree Benefit Payments
Section 10. Health/Dental Care Cash Back
INSURANCE
Section 11. Health Insurance
Section 12. Dental Insurance
Section 13. Life Insurance
Section 14. Long-Term Disability
Section 15. Vision Insurance
Section 16. Other Health and Welfare Payments
LEAVES
Section 17. Vacation
Section 18. Sick Leave
Section 19. Bereavement Leave
Section 20. Holidays
Section 21. Military Leave
Section 22. Leave Of Absences Without Pay
Section 23. Jury Leave
Section 24. Administrative Leave
Section 25. Family Medical Leave
OTHER
Section 26. Retirement
Section 27. Grievance Procedure
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GENERAL
Section 1. Term
This compensation plan shall be for a one (1) year term for the
fiscal year commencing July 3, 1995 through June 30, 1996.
COMPENSATION
Section 2. Salary
The City shall adopt the following salary ranges for each of the
employees in the following classifications.
UNIT 9 EFFECTIVE JULY 3, 1995
Accounting Office. Supervisor $3030 $3,683
Controller $4,087 $4,968
Information Systems Administrator $4,391 $5,338
Legal Secretary $.2,970 $3,610
Principal Planner $4,285 $5,209
Public Works Supervisor $3,562 $4,330
Recreation Supervisor $3,069 $.3,730
Secretary to City Manager $2,970 $3,610
Senior Planner $3,856 $4,687 '
Supervising Civil Engineer $4,838 $5,880
Traffic Engineer $4,838 $5,880
Water System Supervisor $3,734 $4,323
Additionally a 2% increase shall be effective January 1, 1996.
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Section 3. Compensation For Clothing Loss
The City Manager is authorized to provide compensation to City
employees for loss or damage to their clothing which occurs during
the course of carrying out an official duty. A request for
compensation hereunder shall be submitted in writing, in detail, to
the City Manager via the department head concerned. The amount of
compensation, if any, shall be at the discretion of the City
Manager.
Section 4_ Vacation, Payment At Termination
Employees who terminate employment shall be paid in a lump sum for
all accrued vacation leave earned prior to the effective date of
termination.
Section 5. Sick Leave, Payment Of
In the event of the death or retirement of an employee who has
completed ten (10) or more years of continuous service with the
City, the employee shall be paid or shall receive to his/her
benefit, fifty percent (50%) of his/her accumulated but unused sick
leave not to exceed 480 hours.
The employee may elect not to receive this benefit and instead
place all sick leave hours into the PERS Sick Leave Conversion.
Section 6. Deferred Compensation
The City of Petaluma shall make available to the members of this
unit, the City's Deferred Compensation Plan.
Section 7. PERS Employer Paid Contribution
The percentage of each employee's PERS contribution previously paid
by the City prior to the adoption of this Compensation Plan as the
Employer Payment of Member Contribution (EPMC) shall instead be
paid to the employee who shall then pay that amount to PERS. For
purposes of withholding, the City shall defer that portion of the
employee's contribution paid to PERS through Section 414(h)(2) of
the .Internal Revenue Code pursuant to City of Petaluma Resolution
90-363. Therefore, for calculation of base salary at retirement,
the employee shall now have an increased base salary that will
include the total amount of the employee's contribution to PERS
previously paid as EPMC. The employee's contribution will be
withheld from the employee's pay~by the City, and the City will
make the employee's payment of the employee contribution directly
to PERS on behalf of the employee. The employee may not make an
election to take this amount in salary and/or to make the payment
to PERS. The tax exemption does not apply to FICA/social security.
The following is an example of the application of IRC 414(h)(2) as
applied to a miscellaneous employee.
An employee makes $1,000 per month base salary. Under the prior
contract the employee was not responsible for paying 7% of the
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required 7% employee contribution. The City was responsible for
paying 70 ($70.00), which was a City responsibility that was in
addition to the $1,000 base salary.
Under the 414(h)(2) method, the EPMC will revert to salary and the
employee's base salary will now be $1,070. Of this 7%
(approximately $75.00 will be.paid to PERS from the $1,070. The
full 7o will be tax exempt and this means the employee will pay
taxes on $995.0.0.
Section. 8. Work. During A Local Emergency
Members of this. Unit who are required to work during a Council
Declared Local Emergency shall be paid at 1 X their hourly rate for
all hours beyond their normal work day.
Section 9. Retiree Benefit Payment
RETIRED Employees
An employee with twenty (20) years of service and. who is age 50 or
older and who retires on a service retirement during the term of
this agreement, will be eligible for $:95.00 per month beginning on
the retirement date. The payment will decrease in the amount of
$5.00 per year to $0.00 after twenty (20) years if the retired
employee continues in the PEMCHA plan as a retiree. Should the
retired employee. not continue in the PEMCHA plan,. he/she will be
eligible for the full $100.00.., It is the responsibility of_the
retiree to notify the City in writing that he/she is not being
covered by the PEMCHA plan and the City will. commence payment of
the $1.00.00 at the beginning of the month following the receipt of
written notice by the retiree.
Section 10. Health~Dental Care Cash Back
An eligible employee may request cancellation of the employee's
City paid. medical and/or dental insurance coverage-under Section
125 of the IRS Tax Codes upon presentation to the City of
satisfactory proof that he/she has medical and/or dental insurance
coverage from another source. Such a request may be made during
the open enrollment for PEMCHA .medical elections but will be, in
all cases subject to the terms and conditions and cancellation
requirements of the particular plan.
When the employee has demonstrated such coverage to the City's
satisfaction, the City will request cancellation of the employee's
medical and/or dental coverage, subject to the terms and conditions
of the particular policy. Upon actual cancellation of the
employee's medical coverage, and commencing on the date of
cancellation of such policy, the City will instead pay to the
eligible employee, on a monthly basis, an amount equal to 50% of
the "equivalent monthly cost", as defined herein, of insurance
coverage of said employee. In determining the "equivalent. monthly
cost" of such coverage, the City shall calculate the monthly
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premium amount which would be paid by the City on the employee's
behalf under the Health Plan of the Redwoods plan, based on the
employee's coverage level (e.g. self, self plus spouse, self plus
spouse plus children) at the time of such cancellation. However,
if the actual monthly cost of the employee's current plan coverage
is less than the monthly HPR cost, then the lower figure shall be
used. In the event coverage is cancelled only for the employee's
spouse or dependent children, the reimbursement will be 50% of the
cost difference between the old and new levels of coverage (as
calculated using the HPR plan).
Upon such cancellation of the employee's dental coverage, the City
will instead pay to the eligible employee, on a monthly basis, an
amount equal to 50% of the City's internally generated estimated
monthly cost of the self-funded dental costs.
Any employee cancelling coverage will be required to meet all rules
and conditions of the particular plan, including, but not limited
to, all rules and conditions governing administration,
cancellation, and re-enrollment eligibility by requesting a cash
payment pursuant to this section, such employee understands and
agrees as a condition of receipt of this payment, that re-
enrollment eligibility into any plan is not.quaranteed.
INSURANCE
Section 11. Health Insurance
ACTIVE Employees
The City shall participate in the Public Employees' Medical Health
Care Act (PEMCHA) for members of Unit 9. The premium paid by the
City toward this program shall be in the amount of $100.00 per
month per employee.
RETIRED Employees
An employee with twenty (20) years of service and who is age 50 or
older and who retires on a service retirement during the term of
this agreement, will be eligible for $95.00 per month beginning on
the retirement date. The payment will decrease in the amount of
$5.00 per year to $0.00 after 20 years if the retired employee
continues in the PEMCHA plan as a retiree. Should the retired
employee not continue in the PEMCHA plan, he/she will be eligible
for the full $100.00. It is the responsibility of the retiree to
notify the City in writing that he/she is not being covered by the
PEMCHA plan and the City will commence payment of the $100.00 at
the beginning of the month following the receipt of written notice
by the retiree.
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Section 12. Dental Insurance
The City shall provide for a group Delta Dental Insurance Program
for City employee and dependents in this Unit. Additionally, the
City shall contribute toward an Orthodonture plan $'1,000 per child
at a 50% co-payment rate. The City shall pay, during the period of
this Compensation Plan the full premium toward.the City group
dental insurance coverage program.
Section 13. Life Insurance
A. The City shall provide for a group term life ins;ur--ance program
for City employees in this Unit. The City shall pay, during
the course of the Compensation Plan, the insurance premium
towards employee only coverage for such insurance in the
principle sum of $25,000 per employee.
B. Management Life. Insurance shall be in the amount of one and
one-half (1-1/2) times their annual salary rounded to the
nearest even dollar, i.e., $12,000, $13,000, etc. not to
exceed $125,000.
Section 14. Long-Term Disability
The City shall provide a long-term disability plan, premium to be
paid by the City.
Section 15. Vision Insurance.
The City shall provide a Vision Plan for employees and dependents.
The premium shall be paid for by the City.
Section 16. Other Health and 6~Telfare Payments
The City shall provide to the active members of Unit 9 additional
monthly health and welfare payments equal the PEMCHA Health Plan of
the Redwoods premium amounts less $100.00.
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LEAVE
Section 17. Vacation
A.1 Amounts. All regular employees of the City of Petaluma, after
working one full year are entitled to the equivalent of eighty
(80) hours of vacation with pay in the year following the year
in which vacation is earned.
All regular employees of the City of Petaluma, after five (5)
years of continuous service with the City, and beginning with
the sixth year, shall be entitled to the equivalent of one
hundred twenty (120) hours of vacation per year.
After ten (10) years of continuous service with the City,
eight (8) hours of vacation shall be added for each year of
continuous service to a maximum of two hundred (200) hours of
vacation.
A.2 Voluntary Leave Plan
Accruals under the Voluntary Leave Plan shall be prorated to
the work week equivalent hours.
B. Scheduling. The times during a calendar year in which an
employee may take his/her vacation shall be determined by the
department head with due respect. for the wishes of the
employee and particular regard for the needs of the service.
If the requirements of the service are such that an employee
cannot take part or all of his/her annual vacation in a
particular calendar year, such vacation shall be taken during
the following calendar year.
C. Deferral. In the event one or more municipal holidays fall
within an annual vacation leave, such holidays shall not be
charged as vacation leave and vacation leave shall be extended
accordingly.
Section 18. Sick Leave
A. General. Sick leave with pay shall be granted to all
probationary .and regular employees within the competitive
service. Sick leave shall not be considered a right which an
employee may use at his/her discretion, but shall be allowed
only in the case of necessity and actual personal non-service-
connected sickness or off-the-job injury, disability or the
serious illness or injury of an employee's family members,
which requires the employee's attention. The term family
member shall include: spouse, children, parents, spouse's
parents, brothers, sisters or other individuals whose
relationship to the employee is that of a dependent or near
dependent.
8
B.1 Accrual. Sick leave shall accrue to all full-time employees at
the rate of eight hours for each month of continuous service.
No employee shall accumulate more sick leave in any year than
provided
B.2 Voluntary Leave Plan
Accruals under the Voluntary Leave Plan shall be prorated to
the work .week equivalent hours.
C. Notification Procedures. In order to receive compensation
while absent on sick leave, the employee shall notify his/her
immediate superior or the Personnel Office prior to or within
four hours after the time set for beginning his/her daily
duties as may be specified by the head of his/her department.
When absence is for more than: three days/shifts duration, the
employee may be required to file a physician's certificate
with the Personnel Office stating the cause of the absence.
D. Relationship To Workers'. Compensation. Benefits shall be
payable in situations where miscellaneous employee absence is
due to industrial injury as provided in California State
Workers' Compensation Law. During the first three (3) work
days when the employee's absence has been occasioned by injury
suffered during his/her employment and he/she receives
Workers' Compensation, he/she shall receive full pay.
Following this period sick lea-ve may be a supplement to the
Workers' Compensation benefit provided the employee.
Compensation is at his/her regular rate for a period not to
exceed six months or until such sick leave is exhausted, or
the disability is abrogated., or that employee. is certi-fied
"permanent and stationary" by a competent medical authority.
The City shall pay him/her the regular salary, based on the
combination of the Workers' Compensation benefit plus sick
leave.
A11 employees receiving full salaries in lieu of temporary
disability payments pursuant to .Section 4850 of the Labor Code
are entitled to accumulate sick leave during such periods of
sick leave.
Sick leave for industrial injury shall not be allowed for a
disability resulting from sickness, self-inflicted injury or
willful misconduct.
The City may retire any employee prior to the exhaustion of
accumulated sick leave, at which time all accrued but unused
sick leave shall be abrogated, subject only to the limitations
provided under this Memorandum of Understanding.
E. Sick Leave Transfer Policv. Employees wishing to donate hours
of sick leave to another employee may do so by sending a
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written request, approved by their department head, to the
Personnel Office, naming the individual to receive the sick
leave and the amount donated, with the following restrictions:
1. Employees who wish to transfer sick leave must retain a
minimum of 160 hours sick leave to be eligible to
transfer sick leave.
2. All such transfers of sick leave are. irrevocable.
3. The employee. receiving the sick leave transfer must have
zero (0) hours of accrued sick leave, vacation and CTA
left on the books.
4. Employees may not buy or sell sick leave, only the time
may be transferred.
5. Employees may not transfer sick leave upon separation of
service.
6. Sick Leave Transfer shall only be allowed between Units
1, 4, 8, and 9.
7. No more than ninety (90) workdays of Sick Leave may be
received by an employee for any one illness or injury.
Section 19. Bereavement Leave
A.1. In the event of the death of an employee's spouse, mother,
step-mother, mother-in-law, father, step-father, father-in-
law, brother, sister, child, including an adopted. child,
grandchild and grandparent, an employee who attends the
funeral shall be granted time off work with pay. The amount
of time off work with pay shall be only that which is required
to attend the funeral and make necessary funeral arrangements,
but in no event sh-all it exceed three (3) working days.. These
three (3) days shall not be chargeable to sick leave. An
additional two (2) days required for necessary funeral
arrangements may be charged to the employee's sick leave and
any additional time beyond these two days may be charged to
accumulated vacation or leave without pay. Such bereavement
leave shall not be accruable from fiscal year to fiscal year,
nor shall it have any monetary value if unused.
A.2. Voluntary Leave Plan
Accruals under the Voluntary Leave Plan shall be prorated to
the work week. equivalent hours.
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Section 20. Holidays
A. Fixed Holidays. The City shall observe eleven (11) fixed-date
holidays. These holidays shall be established for the City's
fiscal year as determined by City Council resolution.
B. .Floating Holiday. During the period of this Compensation
Plan, City will authorize one (1) "Floating Holiday"' per
employee, which may be taken by the employee. at a time
selected by the employee,. subject to operational requirements
and approval determined by the City. Employees hired between
July 1 and December 31, will be eligible for a Floating
Holiday during the course of the Fiscal Year.
C. Voluntary Leave Plan:
Holidays taken during the Voluntary Leave Plan shall be
prorated to the work week equivalent hours.
Employees on a Voluntary Leave for a fixed period will not be
paid for any holidays falling within the fixed leave period.
Section 21. P~Ii-litany Leave
Military leave shall be arranged in accordance with the provisions
of State Law•. A11 employees entitled to military -leave shall give
the appointing power an opportunity within the limits of military
regulations to determine when such leave shall be taken.
Section 22. Leave. Of .Absence Without Pay
A. The. City Manager may grant a regular or probationary employee
leave of absence without pay pursuant to State and Federal
Law. Good cause being .shown by a written request, the City
Manager may extend such leave of absence without pay or
seniority or benefits for an additional period not to exceed
six (6) months. No such leave shall be granted except upon
written request of the employee setting forth the reason for
the request, and the approval will be in writing. Upon
expiration of a regularly approved leave or within a
reasonable period of time after notice to return to duty, the
employee shall be reinstated in the position held at the time
leave was granted. Failure on the part of an_employee on
leave to report promptly at its expiration, or within a
reasonable time after notice to return to duty, shall be cause
for discharge.
B. Employees may reduce their work week upon approval of their
Department Head and the City Manager under a Vo untary Leave
Without Pay plan, not to exceed 200 of their annual work
schedule. Medical premiums will continue to be paid by the
city and employee as if working a full schedule.
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Section 23. Jury Leave
Every classified employee of the City who is called or required to
serve as a trial juror shall be entitled to absent himself from
his/her duties with the City during the period of such service or
while necessarily being present in court as a result of such call.
Under such circumstances, the employee shall be paid the difference
between his/her full salary and any payment received by him, except
travel pay, for such duty. This compensation shall not extend
beyond twenty (20) working days.
Section 24. Administrative Leave
Members of this Unit are eligible for administrative leave. Days
may be granted by the City Manager upon written request, not to
exceed ten (10) days per Fiscal Year. hours per day.
Section 25. Family Medical Leave Act
Pursuant to the Family and Medical Leave Act of 1993, FMLA leave
may be granted to an employee who has been employed for at least
twelve (12) months by the City and who has provided at least 1,250
hours of service during the twelve (12) months before the leave is
requested. The leave may be granted up to a total of twelve (12)
weeks during the fiscal year for the following reasons:
A. Because of the birth of a child or placement for adoption
or foster care of a child;
B. In order to care for the spouse, son, daughter, parent,
or one who stood in place of a parent of the employee, if
such spouse, son, daughter, parent or "in loco parentis"
has a serious health condition;
C. Because of a serious health condition that makes the
employee unable to perform his employment functions.
The employee must provide the employer with thirty (30 days advance
notice of the leave, or such notice as is practicable, .if thirty
(30) days notice is not possible. The employee must provide the
employer with certification of the condition from a health care .
provider. The employer, at employer expense, may require a second
opinion on the validity of the certification. Should a conflict
arise between health providers, a third and binding opinion, at
employer expense will be sought.
An employee seeking FMLA leave must first use paid sick time (if
applicable) and vacation before going on unpaid leave. The total
amount. of family leave paid and unpaid will not exceed a total of
twelve (12) weeks.. In any case in which a husband and wife
entitled to family leave are both employed by the employer, the
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aggregate number of workweeks of leave to which both may be
entitled may be limited to twelve (12) weeks during any Fiscal Year
if such leave is taken because of the birth of a child or placement
for adoption or foster care of a child. The employee will be
responsible for his/her share of the .health insurance cost during
the leave. If the employee does not return from the leave, he is
responsible for the total insurance premium paid by the employer.
OTHER
Section 26. Retirement
A. General
The City of Petaluma's retirement plan under the Public Employee's
Retirement System shall consist of the following items:
Miscellaneous Employees: 2% @ 60
Option: 1959 Survivors Benefit (Level 1),
One Year Final Compensation.
Military Service Credit as Public Service.
Unused Sick Leave credit.
Section 27. Grievance Procedure
A. Purpose of Rule
1. To promote improved employer-employee relations by
establishing grievance procedures on matters for which
appeal or hearing is not provided by other regulations.
2. To afford employees individually or through qualified
employee organization a systematic means of obtaining
further consideration of problems after every reasonable
effort has failed to resolve them through discussions.
3. To provide that grievances shall be settled as near as .
possible to the point of origin.
4. To provide that appeals shall be conducted as informally
as possible.
B Matters Subject To Grievance Procedure. Any employee in the
competitive service shall have the right to appeal under this
rule, a decision affecting his/her employment over which
his/her appointing power has partial or complete jurisdiction
and for which appeal is not provided by other regulations or
is not prohibited.
C.. Informal Grievance Procedure. An employee who has a problem
or complaint should first try to get it settled through
13
discussion with his/her immediate supervisor without undue
delay. If, after this discussion, he/she does not believe the
problem has been satisfactorily resolved, he/she shall have
the right to discuss it with his/her supervisor's immediate
supervisor, if any, in the administrative service. Every
effort should be made to find an acceptable solution by
informal means at the lowest possible level of supervision..
If the employee does not agree with the decision reached, or
if no answer has been received within five (5) calendar days,
he may present the appeal in writing to the City Manager.
Failure of the employee to take further action within five (5)
calendar days after receipt of the decision or within a total
of fifteen (15) calendar days if no decision is rendered, will
constitute a dropping of the appeal.
D. Formal Grievance Procedure
(Levels of review through chain of command)
(1) First level of review. The appeal shall be presented in
writing to the employee's immediate supervisor, who shall
render his/her decision and comments in writing and return
them to the employee within five (5) calendar days after
receiving the appeal. If the employee does not agree with
his/her supervisor's decision, or if no answer has been
received within five (5) calendar days, the employee may
present the appeal in writing to his/her supervisor's
immediate superior. Failure of the employee to take further
action within five (5) calendar days after receipt of the
written decision of his/her supervisor, or within a total of
fifteen (15) calendar days if no decision is rendered, will
constitute a dropping of the appeal.
(2) Further level or levels of review as appropriate. The
supervisor receiving the appeal shall review it, render
his/her decision and comments in writing, and return them to
the employee within .five (5) calendar days after receiving the
appeal. If the employee does not agree with the decision, or
if no answer has been received within five (5) calendar days,
he/she may present the appeal in writing to the department
head. Failure of the employee to take further action within
five (5) calendar days after receipt of the decision or within
a total of fifteen (15) calendar days if no decision is
rendered, will constitute a dropping of the appeal.
(3) Department Review. The department head receiving the
appeal of his/her designated representative, should discuss
the grievance with the employee, his/her representative, if
any, and with other appropriate persons. The department head
shall render his/her decision and comments in writing, and
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return them to~the employee within five (5) calendar days
after receiving the appeal. If the employee does not agree
with the decision reached, or if no answer has been received
within .five (5) calendar days after receipt of the decision,
or if within a total of fifteen (15) calendar days no decision
is rendered, it will constitute a dropping of the appeal.
(4) City Manager. The City Manager receiving the, appeal or
his/her designated representative should discuss the grievance
with the employee, his/her representative, if any, and with
other appropriate person(s). The City Manager .may designate a
fact-finding .committee, officer not in the normal line of
supervisor, or Personnel Board to advise him concerning the
appeal. The City Manager shall render a decision in writing
to the employee within twenty (20) calendar days. after
receiving the appeal.
(5) Conduct of Grievance Procedure.
(a) The time limts_specified above may be extended to a
definite date by mutual agreement of the employee
and the reviewer concerned.
(b) The employee may request the assistance of another
person of his/her own choosing in preparing and
presenting his/her appeal at any level of review.
(c) The employee and his/her representative may be
privileged to use a reasonable amount of work time
as determined by the appropriate department head in
conferring about and presenting the. appeal.
(d) Employees shall be assured freedom from .reprisal for
using the grievance procedures.
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REQUEST FOR FAMILY/MEDICAL LEAVE
Employee Name:
Date of Request: Department:
Position Title: Hire Date:
I request a Family/Medical Leave for the following reason (check one):
A. The birth of a child and/or in order to care for such child.
B. The placement of a child for adoption or foster care.
C. In order to care for an immediate family member because such family
member has a serious health condition. Circle one: CHILD SPOUSE
PARENT (Must submit "Physician Certification" within 15 days).
D. My own serious health condition that makes me unable to perform the
functions of my position. (Must submit ':'physician Certification"
within. l5 days).
METHOD OF LEAVE REQUESTED
Consecutive Leave
Intermittent or Reduced Leave Schedule
(Specify Schedule Below)
Date leave is to begin:
Expected duration of leave:
If the duration of my family/medical leave (total of paid and unpaid time) does
not exceed 6 months, I will be returned to my same, equivalent or comparable
position.
Employee's Signature Date
~E~®.J~®257N~S
y
~~sr City of Petaluma 11 English Street
Posr Office Box 61 Petaluma, California 94953
1838
Employer Response to Employee Request for Family or Medical Leave
Date:
TO:
(Employee's Name)
FROM:
(Personnel Director)
SUBJECT: Request for Family/Medical Leave
On ,.you notified us of your need to take family/medical
(date)
,leave due to: (check one)
the birth of. your child, or the placement of a child with you for adoption
or foster care; or
.a serious health condition that makes you unable to perform the essential
functions of your job; or
_ a serious health condition affecting your spouse, child., parent, for
which you are needed to provide care.
You notified us that you need this leave beginning on and that
(date)
you expect leave to continue until on or about
(date)
Except as explained below, you have a right under the FMLA for up to 12 weeks of
unpaid leave during the Fiscal Year for the reasons listed above. Also, your
health benefits must be maintained during any period .of unpaid leave under the
same conditions as if you continue to work, and you must 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. If you do not return to work following FMLA
leave for a reason other than: (1) continuation, recurrence, or onset of a serious
health condition which would entitle you to FtiII,A leave; or (2) other circumstances
beyond your control, you. may be required to reimburse us for our share of health
insurance premiums paid on your behalf during your FMLA leave.
This is to inform you that: (check appropriate boxes; explain where indicated)
Ir You are eligible not eligible for leave under the FMLA. .
II. The reques ed leave will will not be counted against your annual FMLA
leave entitlement.
III. You _will _will not be required to furnish medical certification of a serious
health condition. If required, you must furnish certification by
(must be at least 15 days after you are notified of this requirement) or we may
delay the commencement of your leave until the certification is submitted.
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1V. You may elect to substitute accrued paid leave for unpaid FMLA leave. We
caill' _wi11 not require that you substitute accrued paid leave to unpaid•
FMLA leave. If paid leave will be used the following conditions will apply:
V. If you nor,~ally pay a portion of the premiums for your health insurance,
these payments will continue during the period of FMLA leave. Arrangements
for payment have been discussed with you and is agreed that you will make
premium payments as follows: (Set forth dates, e.g., the 10th of each month,
or pay periods, etc. that specifically cover the agreement with the employee.)
You have a minimum 30-day (o r, indicate longer period, if applicable) grace
period in which to make premium payments. If payment is not made timely,
your group health insurance may be cancelled, provided we notify you in
writing at least 15 days before that date that your health coverage will
lapse, or at our option, we may pay your share of the premium during FMLA
leave, and recover these payments from~you upon your return to work. We
will will not pay share of health insurance premiums while you are on
leave.
We _will will not do the same with other benefits (e.g., life insurance,
disability insurance, etc.) while you are on Fi~1LA leave. If we do pay your
premiums for other benefits, when you return from leave you _will _will not
be expected to reimburse us for the payments made on your behalf.
VI. You _will will not be required to present a fitness-for-duty certificate
prior to being restored to employment. If such certification is required but
not received, your return to work may be delayed until the certification is
provided.
VII. You _are _are not a "key employee" as described in 825.218 of the FMLA
regulations. If you are a "key employee", restoration to employment may be
denied following FMLA leave on the grounds that such restoration will cause
substantial and grievous economic injury to us.
We _have _have not determined that restoring you to employment at the
conclusion of FMLA leave will cause substantial and grievous economic harm
to us .
VIII. While on leave, you will _will not be required to furnish us with periodic
reports every of your status and intent to return to c•~ork. If the
circumstances of your leave change and you are able to return to work earlier
than the date indicated on the reverse side of this form, you _will will not
be required to notify us at least two work days prior to the date you intend
to report for work:
IX. You _will _will not be required to furnish recertification relating to a
serious health condition.
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PHYSICIAN OR PRACTITIONER CERTIFICATION
SERIOUS HEALTH CONDITION
Employee's Name:
Patient's Name (if other than employee):
Diagnosis:
Date condition commenced:
Duration of Medical Leave; From: To:
Regimen of treatment to be prescribed (indicate number of visits, general
nature and duration of treatment, including referral to other provider of
health services. Include schedule of visits or treatment if it is med-
ically necessary for the employee to be off work on an intermittent basis
or to work less than the employee's normal schedule of hours per day or
days per week.):
By Physician or Practitioner
By other provider of health services; if referred. by Physician or Practitioner:
Check Yes or No in the space below as appropriate.
I, Yes_ No_ Is inpatient hospitalization of the family-member (patient) required?
II. Yes_ No_ Does (or will) the patient require assistance for basic medical,
hygiene, nutritional needs, safety or transportation?
III. Yes_ No_ After review of the employee's signed statement, is the employee's
presence necessary or would it be beneficial for the care of the
patient? (This may include psychological comfort.)
IV. Estimate the period of time care is needed or the employee's presence would be
beneficial:
V. When Family Leave is needed to care for a seriously ill family member, the
employee shall state the care he or she will provide and an estimate of the
time period during which this care will. be provided, including a schedule if
leave is to be taken intermittently or on a reduced leave. schedule.
Employee's Signature: Date:
Signature of Physician or Practitioner:
Date:
Type of .Practice (Field of Specialization, if any)
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CITY OF PETALUMA
FITNESS FOR DUTY TO RETURN FROM LEAVE CERTIFICATION
On the Employee began a period of family/medical care
(mo./day/yr)
from the City of Petaluma .for Based on mv_
(diagnosis)
examination of on
(employee's name) (date of examination)
I certify that he/she is medically/psychologically fit to return to work with the
following limitations:
(list limitations if applicable)
Date:
Signature of Physician or Practitioner
Type of Practice (Field of Specialization, if any)
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CITY OF PETALUMA
AUTHORIZATION FOR PAYROLL DEDUCTIONS FOR BENEFIT COVERAGE
CONTINUATION DURING FAMILY/MEDICAL CARE LEAVE
I authorize the City of Petaluma to made deductions from income I will
receive from accrued .leave during my upcoming family/medical care leave
which will commence on and end on
(date leave will start)
(date leave will end)
I authorize deduction to be made from income I will receive from accrued
leave for the following benefits:
Employee's Signature Date
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CITY OF PETALUMA
INTEROFFICE MEMORANDUM
To: Personnel Department
From:
SUBJECT: REQUEST FOR WAIVER/CANCELLATION OF MEDICAL/DENTAL COVERAGE
This is to verify that I am currently covered by my spouse's
insurance. As a result, I would like to cancel/waive my insurance coverage effective
on the following:
A letter verifying coverage by my spouse's employer is attached.
As per the current MOU, upon cancellation/waiver of my insurance coverage, I request
the amount I am eligibleto be paid. I qualify for an amount based on the
party rate, because I have number of dependents.
I understand that if I cancel my insurance I am subject to the re-enrollment policy
of the PEMCHA Health Plan as provided by the City.
Employee's Signature Date
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