Intake Form: # 3622296

Type of Claim : FMLA for Family Member

Personal Information
Last Name : AJAEGBU First Name : TONIKA
Nickname : Date of Birth : 12/12/81
Middle Init. : N Gender: FEMALE
Home Address
Street Address (Home) : 900 143RD AVENUE Line 2 (optional) : APT 109
City : SAN LEANDRO State : CA
Zip Code : 94578 Home Phone Number : 5107504656
Which address would you like us to mail communications to you? : My eServices Account
Reason for Leave
Reason For Leave : Critically ill - cardio issues, diabetic, CHR
Return to Work Information
What was or will be your last day of Work : 12/19/2018
First Leave Date : 12/20/2018
Last Leave Date :
Have you returned to Work? : NO
What is your estimated return to work date : 01/31/2019
Intermittent or Continuous
Are you requesting Leave on an intermittent / part-time basis? : NO

Additional Information
Date of Hire : 08/15/2016
Original Date of Hire : 08/15/2016
The person completing the form is the person requesting the leave of absence? : YES

Send Information to eServices? : NO

Temporary Contact Address1 :
Temporary Contact Address2 :
Temporary Contact City :

Temporary Contact State :

Temporary Contact Zip :

Temporary Contact Address Date :

Temporary Contact Home Phone :

Temporary Contact Cell Phone :

Temporary Contact Start Date :

Temporary Contact End Date :

Approval to send Text ? : YES

Cell Number is allowed to Use? : YES

Number to send Text message : Yes

Absent Three or more Days? : YES

Is Chronic Condition More Time off ? : NO

Work Address
State : CA
Work Information
Department / Location : HGH MED/SURG 9th Floor Job Title : CLINICAL NURSE II
Employee ID : 000012756
Are you a full time employee : YES
Are you Exempt? : NO
Do you work Monday through Friday 8 hours per day? : YES
Supervisor and HR Information
Supervisor's Name : OKORIE JOVITA C. HR Representative's Name: :

Supervisor's Email Address : Hr Email Address :

jokorie@alamedahealthsystem.org
Supervisor Phone : HR Phone Number :

Have you notified your supervisor of your absence? :

Misc. Information
Do you have more than one Employer? :

Additional EE will call back with Father¿s DOB EE will take Med Cert to Doctor. EE works 3 days per
Comments : week, 12 hours per day, days vary.

FMLA - Family Member Information

Family Member's Last Name : Ajaegbu Family Member's First Name : Barmabas
Family Member's Middle Initial : Gender : M
Member Date of Birth : Address :
City : Imoowerii State :
Zip Code : Phone Number :
What is the relationship of this family member to you? : Parent
International Address (if applicable)
Address : Home Country if not US : NIGERIA
Physician Information
Physician's Last Name : Physician's First Name :
Street Address : Line 2 (optional) :
City : State :
Zip Code : Physician's Phone Number (including area code) :
Physician's Fax Number (including area code) : Medical Specialty :

Date of your family member's last visit to their Physician :

When is your next scheduled office visit :
Are you seeing another physician or specialist :

Injury Or Health Condition Description Critically ill - cardio issues, diabetic, CHR

Health Insurance Provider Other

Health Insurance ID Number

Past Missed Time Report Flag NO

Income Information
Have you ever worked for ALAMEDA HEALTH SYSTEM as a temp employee? :

Custom Questions
To help ensure that you are paid appropriately during your leave, please confirm by answering
Yes.
Yes or No to the following: Are you planning to apply for EDD benefits during your leave?

Reminders

Alameda Health System has an Employee Assistance Program (EAP) that provides free and
confidential resources to help maintain or regain your health and well-being. The EAP can assist
with relationship issues, financial difficulties, childcare and eldercare resources and educational
information, alcohol or drug abuse, marital conflicts, grief and trauma, legal concerns, emotional YES
issues, and psychological disorders. Call Managed Health Network, Inc. (MHN) toll-free, 24 hours
a day, seven days a week at 1-800-227-1060 or visit them online at members.mhn.com and
register with the company code: ahs

As a California employee, you may be entitled to a Paid Family Leave Benefit. If your claim is
YES
approved, you will receive your payment directly from the state of California.

You may receive automated phone messages from Matrix Absence Management providing you
YES
updates regarding your claim. There is no need to call us back unless you have questions.

Extended sick leave may be used for periods of illness that exceed one (1) week. The first week
of such an illness will be covered by PTO. Exceptions to this rule are detailed in our policies and YES
procedures and/or your respective Memorandum of Understanding (MOU).

After your leave status is updated, Payroll assumes that you will apply for Employment
Development benefits. If you are in-eligible or do not wish to apply for these benefits, you must
confirm this with Payroll via e-mail Payroll@alamedahealthsystem.org or by phone at 510-346-
YES
7505 prior to the first day of your leave to ensure that you are paid correctly while on leave. Your
manager may call you during your leave to discuss updates regarding your situation and your
eventual return to work.