HomeMy WebLinkAbout01-2217 FX
i'>>::};"-'
,--.
,
..
,jl. (;1 - ),)" I 7
(1( "c~L
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this Complaint and Notice are
served, by entering a written appearance personally or by attorney and filing in writing with the court,
your defenses or objections to the claims set forth against you. You are warned that if you fail to do
so, the case may proceed without you and a judgment may be entered against you by the court without
further notice, for any money claimed in the Complaint or for any other claim for relief requested by
the Plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HA VB A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Lawyer Referral Service
1 Liberty Avenue
Carlisle, Pennsylvania 17013
(717)
!I!III!, "
~~~~
""~~~,~:
~
NOTIClA
Le han demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas
en las paginas sigiuentes, usted tiene veinte (20) dias de plaza al partir de la fecha de la demanda y la
notificacion. Usted debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en la
corte en forma escrita sus defensas 0 sus objeciones alas demandas en contra de su persona. Sea
avisado que si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin
previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda.
U sted puede perder dinero 0 sus propiedades 0 otros derechos importantes para usted.
LLEVE ESTA Dm"lANDA A UN ABOGADO INMEDIATEMENTE. SI NO TIENE
ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVIClO, VAYA
EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECClON SE
ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUlR
ASISTENCIA LEGAL.
Cumberland County Lawyer Referral Service
1 Liberty Avenue
Carlisle, Pennsylvania 17013
(717)
".,
,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
DEAN TEETER,
v.
CIVIL ACTION NO.:
~/- c))./7 (!tA-;'~
APPLETON PAPERS, INC.,
Defendant
: JURY TRIAL DEMANDED
COMPLAINT
1. Plaintiff, Dean Teeter, is an individual who resides at 1605 Walnut Street, Camp Hill,
Pennsylvania, 17011.
2. Appleton, Appleton Papers, Incorporated, (hereinafter "Appleton") is a corporation
organized, operating and existing under the laws of the Commonwealth of Pennsylvania, which has
its local place of business at 2850 Appleton Street, Mechanicsburg, Cumberland County,
Pennsylvania 17055.
3. At all times relevant hereto, plaintiff was employed in a second-hand operator's position
at Appleton's Mechanicsburg, Pennsylvania plant.
COUNT I
WRONGFUL DISCHARGE
4. The allegations contained in paragraphs one (1) through three (3) of this complaint are
incorporated herein by reference as though fully set forth.
5. On or about April 7, 1986, plaintiff became employed by Appleton. He held his current
position as a second-hand operator position for approximately thirteen (13) years.
6. On or about March 3, 1999, plaintiff injured his left arm, elbow and hand, while in the
course of his employment.
7. As a result of the March 3,1999 injury, plaintiff received surgical intervention on April
12,1999, by Appleton's panel physician, Dr. Robert]. Maurer.
8. Plaintiff received a re-graphed nerve followed by eight (8) weeks of rehabilitative therapy
prior to his return to work.
9. Appleton accepted plaintiffs accepted workers' compensation claim as a result of the
March 3,1999, injury. The period of accepted workers' compensation was March 3,1999 through
July 5, 1999.
-, ~~,=,~"'"
co
I I '
~.
"~ "
',flmUJ, ~
,
10. On or about July 5, 1999, Dr. Maurer instructed plaintiff to return to his pre-injury work
position.
11. Following his return to work, plaintiff began experiencing numbness, pain and
aggravation at the surgical point in his left arm. He reported these problems to his supervisors.
12. On or about July 27,1999, plaintiff obtained a second opinion from his own physician,
Morton L. Rubin, MD., F,A.C.S. Dr. Rubin is an orthopedist.
13. Dr. Rubin directed plaintiff not to return to the pre-injury work position.
14. Dr. Rubin is of the opinion that plaintiff has sustained a repetitive work injury.
15. Dr. Rubin approved plaintiff for work in any position not involving repetitive motion
with plaintiffs left arm.
16. Appleton was advised of Dr. Rubin's instruction for plaintiff to return to light duty with
no repetitive motion of his left arm.
17. Appleton refused to provide any light duty work for plaintiff.
18. On or about August 3, 1999, Appleton informed plaintiff that they would not be
accepting his workers' compensation injury claim.
19. On or about August 5, 1999, plaintiff filed a Reinstatement Petition for workers'
compensation benefits.
20. On or about August 18, 1999, Appleton filed an Answer to plaintiffs Reinstatement
Petition. Once again, Appleton denied his requests.
21. Appleton has never offered plaintiff light duty work.
22, Plaintiff followed Appleton's procedures for medical leave and completed all requisite
forms necessary for leave.
23. On or about October 25, 1999, Plaintiffs name appeared as having been terminated and
was displayed at Appleton on the employee status bulletin board. (See, Finishing Department
Schedule 25 October 1999, attached hereto as Exhibit A).
24. Appleton fired plaintiff on November 2, 1999.
25. Plaintiff was on an accepted leave of absence on November 2, 1999.
.,..,
, ""
~I
=-"--.
26. Appleton knew that plaintiff was on an accepted leave of absence when they fIred
plaintiff. (See, Request for Leave of Absence or Family/Medical Leave of Absence forms, attached
hereto as Exhibit B,)
27. Appleton's human resources manager, James A. HonafIus, testifIed at a union grievance
hearing and workers' compensation hearing that plaintiff was fued while on an accepted leave of
absence. (See, Notes of Testimony from Workers' Compensation Hearing on February 22, 2001,
page 17, attached hereto as Exhibit C).
28. Plaintiffs termination by Appleton violates public policy, was in violation of Appleton's
legal and ethical obligations and was intended to punish plaintiff for filing for workers'
compensation.
29. The conduct of Appleton, acting through its agents, servants, workmen and/or
employees, as set forth in this Complaint, amounts to a wrongful discharge of plaintiff.
WHEREFORE, plaintiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00, plus interest, costs and attorney fees.
COUNT II
VIOLATION OF THE AMERICANS WITH DISABILITIES ACT
31. Plaintiff incorporates by reference the allegations in paragraphs 1 through 30 as though
set forth herein.
32. Plaintiff has exhausted his administrative remedies and been granted a Right to Sue
letter from the Equal Employment Opportunities Commission (EEOC). (See, Right to Sue letter,
attached hereto as Exhibit D).
33. Plaintiff is mentally/physically disabled as defined by the ADA.
34. Plaintiff is a qualifIed individual with a disability within the meaning of the ADA.
35. Appleton discriminated against plaintiff because of the disability.
36. Appleton terminated plaintiff because of his work-related injury.
37. Appleton's termination of plaintiff is a discriminatory action prohibited by the ADA.
38. Appleton's discriminatory conduct as to plaintiff was taken with malice with reckless
indifference to the federally and state protected rights of plaintiff.
-F'
.~\
I ~I
. ~,~""" '- ~.~,
39. Appleton's termination of plaintiffs employment has caused, continues to cause and will
cause plaintiff to suffer substantial damages for future pecuniary losses, mental anguish, loss of
enjoyment of life, and other non-pecuniary losses.
WHEREFORE, Plaintiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00. This demand is for all wages lost since November 2,1999, through the
present, interest on all wages lost since November 2, 1999, to the present, future pecuniary losses,
mental anguish, loss of enjoyment of life, and other non-pecuniary losses, and costs of this action,
including expert witness fees and attorney's fees.
COUNT III
VIOLATION OF THE FAMILY MEDICAL LEA VB ACT
40. Plaintiff incorporates by reference the allegations in paragraphs 1 through 39 as though
set forth herein.
41. Appleton employed more than fifty (50) employees at the location where the plaintiff
worked.
42. Plaintiff worked in excess of 1,250 hours at Appleton's place of business in the twelve
(12) months preceding his request for leave under the Family and Medical Leave Act, hereinafter
referred to as "FMLA."
43. On September 8,1999, Plaintiff requested leave under the FMLA, 29 U.S.CA. ~2612.
Plaintiff was unable to perform the functions of his position due to his health condition.
44. On October 4,1999, Plaintiff requested leave under the FMLA, 29 U.S.CA. ~2612.
Plaintiff was unable to perform the functions of his position due to his health condition.
45, Appleton denied plaintiffs requests for leave under FMLA.
46. Appleton never requested nor required plaintiff to obtain certification issued by his
health care provider, as permitted pursuant to 29 U.S.CA. ~2612.
47. Appleton denied plaintiffs exercise of rights provided under the FMLA.
48. Appleton discharged the plaintiff due to his repeated requests for leave under the
FMLA.
49. Appleton's firing of plaintiff is in violation of the FMLA.
WHEREFORE, Plaintiff detnands judgment in his favor and against Appleton in an amount
in excess of $25,000.00. This demand is for all wages lost since November 2, 1999, through the
'11
~" ,~.O 't -
f"!'"fO,^,<"
~~ ,"
-
. ~-... ~.~,~~""~'''''"'
present, interest on all wages lost since November 2, 1999, to the present, liquidated damages in an
amount equal to plaintiffs lost wages and interest thereon from November 2, 1999, to the present,
and costs of this action, including expert witness fees and attorney's fees.
COUNT IV
INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS
50. Plaintiff incorporates by reference the allegations in paragraphs 1 through 49 as though
set forth herein.
51. Appleton's conduct in firing plaintiff while on an accepted leave of absence and a work-
related injury, was extreme and outrageous.
52. Appleton's conduct intentionally caused plaintiff emotional distress.
53. Appleton's conduct was with the reckless disregarded for causing plaintiff emotional
distress.
54. Plaintiff has suffered severe or extreme emotional distress as a result of Appleton's
conduct,
55. Appleton's conduct caused plaintiff's emotional distress.
WHEREFORE, Plaintiff demands judgment in his favor and against Appleton in an amount in
excess of $25,000.00 plus interest, costs and attorney's fees.
COUNT V
56. Plaintiff incorporates by reference the allegations in paragraphs 1 through 55 as though
set forth herein,
57. The conduct of Appleton, as more fully set forth above, was outrageous, intentional,
malicious, willful and in blatant disregard for the rights of plaintiff.
58. As a result of said conduct, Appleton is liable to plaintiff for punitive damages.
WHEREFORE, Plaintiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00 plus interest, costs and attorney's fees.
fLE:<,;E<'.TA,tu..y -< '-cfipl Tn,-n
\ ~~
($u'l:(l
g: ~\lUlJ.( t!tI~ovez. J).
~fU; P9 /70/5
'q~"
, .
1 ,
. '
I
CERTIFICATE OF SERVICE
AND NOW, this 16th day of April, 2001, I, Jason P. Kutulakis, Esquire, hereby certify that I
did serve a true and correct copy of the foregoing ENTRY OF APPEARANCE AND
COMPLAINT ON BEHALF OF PLAINTIFF upon all counsel of record by depositing, or
causing to be deposited, same in the u.s. mail, postage prepaid, at Harrisburg, Pennsylvania, addressed
as follows:
By First-Class Mail:
Robert J. Goduto, Esquire
Duane, Morris & Heckscher, LLP
305 North Front Street, 5th Floor
P.O. Box 1003
Harrisburg, PA 17108-5500
.,
,j.""4
n p, Kutulakis
"t'_L
I I
. r-.
-
-
_I
DEAN TEETER,
Plaintiff
v.
APPLETON PAPERS, INC.,
Appleton
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION NO.:
: JURY TRIAL DEMANDED
ENTRY OF APPEARANCE
Please enter the appearance of the undersigned as counsel for Plaintiff, Dean Teeter, in the
above-captioned matter.
Dated: ~_I&-O I
iT , ' ~ _~,
- ~~1 T-'
Respectfully submitted,
ABOM & KUTULAKIS
Jason . Kutulakis
Attorn yLD. 80411
8 South Hanover Street, Suite 204
Carlisle, P A 17013
Attorney for Plaintiff
,-,-
CERTIFICATE OF SERVICE
AND NOW, this 16th clay of April, 2001, I, Jason P. Kutulakis, Esquire, hereby certify that I
did serve a true and correct copy of the foregoing ENTRY OF APPEARANCE AND
COMPLAINT ON BEHALF OF PLAINTIFF upon all counsel of record by the method listed
below:
Cumberland County Sheriff:
Appleton Papers, Incorporated
2850 Appleton Street
Mechanicsburg, P A 17055
First-Class Mail
Robert J, Goduto, Esquire
Duane, Morris & Heckscher, LLP
305 North Front Street, 5th Floor
P.O. Box 1003
Harrisburg, PA 17108-5500
'f1 ^"~ "_
, ; _4' , .~=
"
~, '1 '"I -
. ~, ,
--~
:1\
'"
'"
...
~
=
'~
Q
III
~
~
=t
Q 'c
Ill' ~
~f
EI
~l
c::ll
c
lO.
l!
i
:2
III
~
. ;t......-.ilf.~:...~ ...
, , l j
if ill1 i
~ ~ 11
, ~ I iliiilU i
, !!l ~:! q q q
...R ~_
-
el ~
i : IHUIU !
i; -
g;
. ~ ~ ! II ~ ;<
- ~..- ..- \7 Iii ~
I i ;2 ~ ml I
li:!;li3j il!~~g ~i
! i B c s i~ ~I~ 51
~ !:i i i 'I
~
I
I
-;U
J;
- -
~..-" ~
i!-Ilea
II!! =Icuu
Lh
..
. jii llea.1> I
o iEE i ~
~ ;~. .. Ilea.v
i= ~ 'Hli;t'lll- iJ;Ol::1l< ill ..
lit ~! ~;!!S -~,U &, liIl'. l1j
u .... ......... ..."1'..... 4_ ! ~ ...ca III
~ ~ff g
I! t i I ·
! Idhlh'i Imli Jj.... ~
i llllU:, lit In i i
~
HiUhiihiUlil al.... i
! i~~U:l q:u t
lln
h
''!'S'li~~'i'r.'"""",,~,;,,~ _ ,_, ,~J!!,_" ""~,~__, ..,...,.,. ~_~" r
I_~I,;-- '__~;::
"'T\
Name: ~,I' It-lei
Department:
Extension' (circle one)
Request for:
Leave of Absence or Family/Medical Leave of Absence
->~ :-
V/.< i" ,,"'.'
Date: I~' / ./ /'
~-
, ,
.'/ t:'\{" ~:, '~.~_.'
,,~~f."' 1.;;""../'-
Employee #:
Supervisor: l.
If Yes date original leave began'
"':l. l
......;1 /- <..;: i /.r' f
.-' .. f ,/
~!'.. ,-, /; ';;'
, , , ,
I, hereby request L~'avE;of Absence: (i.e., non-FMLA leave, military leave, personal)
Facts nertaininn to this leave: ; ,,', , ,
,
"
,
I Projected return to work date: ' ' ','
Request leave to start:
/ NO\ or YES
;r!.: I hereby request a Family/Medical Leave of Absence (FMLA) from work for the purpose
,
My own serious illness, work-related injury/illness
My own serious illness, non work-related injury/illness .' ..,. ,,'... , ", .. ,.
Birth of a child or placement of a child for adoption/foster care. E;xpec.teddue date:
Caring for a sick child, spouse or parent " .
Medical or Informational Facts ertainin to this leave:
If a licable Date of illness:
Ph sician/Health Provider Statement attached .Yes\ or
Request leave to start: ?
Date of the next 9octor's appointment: '" L.'.#!;l 1'0/\
DocumentatioI!~~ZWill be provided on: Date: J/:J.// /
To: .' ;?([~.,: /:/:~,~ ~- iI;'
- "- - '--, ,..':------,,~': :.:'".' -: '_.,::~-'- {'-:;-,' .-;":~:':~~:',-'- .
Employees on medical leave will provide an Appleton papers InG. Return to liVorkSlipsigneq by their
doctor or personally provide documentation signed by their doctor to extel1dllJeirleavepl1.' '
by 12:00 noon to . , ," ".., ,."'l."
(Date) " , . .' " ,', (Name) ," ,.,,', .,",,'.. ,'" .
Failure to personally provide documentation to extend this Leave of Absenceorfailure.to retyrntowork on the employee's first"
scheduled day of work will result in loss of seniority (~mployment) in accordance with Article 6.6Eofthe LaboiAgreem'ent.
---- ' .,,',,, ....,' , ,.y'
/ '.
I Additional Comments:
Employee Signature:
Steward's Acknowledgement:
~7 ~.,
.,.. i .."'"
I.II" .""'" ',I,"'-':;'-----'" ,""
J ' ," .--- "-. ,'" .'
''/:,' " v,,1;;
,-,;,,/ __,,'v ."f.~":':~,;;.,' fV
'-~- )' -1..../
I
'-",
Date:
:~;,--~\ -::~':~ :~2j;;~:::
.
Date: .!l;;;,'1Z. "
Approved by (FMLA ONLY):
~ .<:;:2}:#-,-
...-:_ '\ C
Supervisor:
Department Manager:
" ". "
"--~._~~:'. ~::~~-
Date:
Date:
Date;
:> \'7
;-:'
''<....
'-/UF_~.d.~~'~-~A____i
';"'-
-,-,
'."-"'! .'"
,-,(_\ oJ
/' ! "
Human Resources: ......--'':':;."',
-.-" ..
, "
- - ,,:~ " : .'
.,,:.:-'c_",
, ,
Note: This Leave of Absence Request is not appro'1e~ until all signature approvals are obtained by aU parties or their de.'eg~tes.
,VVhite' Payroll
Green: Medical
. - .
',;- ','
las:\forms\loa-formi1
Canary HR File
Pink: Department,
"~,""'El1~",,~~.,~_>_,~,,,,", "V-IM'-r ,"1
~~~r I~
-
1ImI!IllIlI~1II!l't' ~ "".~""'" ,...,~ _ ~ '''' =...Yi
Request for:
Leave of Absence or Family/Medical Leave of Absence
Name: - v 1. -;__-(" ",~, --{,J. '.,'. C ",_,,- r
Department: i
Extension: (circle one) NO or, YES'>
I hereby request Leave of Absence:
Facts ertainin to this leave:
'J,c
Employee #:,. ' / Date:
Supervisor:
If Yes, date original lealie began: ,
.- "
(Le., non-FMLA leave, rt,[litlryleave, personal)
Request leave to start:
Projected return to worK~ate>'
I hereby request a Family/Medical Leave of Absence (FMLA) from work for the purpose
My own serious illness, worK-related injury/illness
My own serious illness, non worK-related injury/illness
Birth of a child or placement of a child for adoption/foster care 'e:.xp~<:ted due date:
Caring for a sick child, spouse or parent
Medical or Informational Facts ertainin to this ieave:
, '(,'
If a licable Date of illness:
Ph sician/Health Provider Statement attached Yes or
Request leave to start:
Date of the next dQctor'sappointment: ..:-:.. 3/ ;1/
DocumentatiorrwCjs/will be provided on: Date: ..
i~c1Ud~s needtd care for illfamil member
.,-,,' -j
-U /0 ,.. /. "'j_ ;.,
ill)/
To:
-', "
. .~~ .,' .
,r ,,"
. '. ~' :)-" . ~., -::- ,j ,','
Employees on medical leave will provide an Appleton papers Inc. Ret{jr;ntq Work Slip ~igned by their
doctor or personally provide documentation signed by their doctor toextendt~eitleav~on
by 12:00 noon to ' , '
(Date) /(Nal'lle),' ,
Failure to personally provide documentation to extend tilrs leave of Absence or failure toretqrn to. work on the E\rnpioyee's first
scheduled day of work will result in loss of seniority (employment) in accordance with'!"rtic.le 6,6E of the labor Agreement '
, ;'_';~Sj_:_' ",:~, !:. -;., -~ -'. ,-:,.
I Additional Comments:
Emp.loyee Signature:
Steward's Acknowledgement:
<'
~." ~ .c ,_ >_~
".. . ,.,',..".'1
'''--', , -~, -.
.--'
,,!,.,
.
; . ~;..c'''-f; .~.. ",' ",
Date:
,: Da.te:
} ::,')-
/
t
. '-":-
,"';';,
Approved by (FMLA ON!,..~): ~ '
/'- , <{.-:'l,
/ / //
Supervisor: i .'1 !
} j
~,~--
/'- !.~
, ;i
. i
! J-
!"';';
Date:
",/'
-'/1' /7 I
~ /' I
,J il ?/;,--),~)
f. ,.
Department Manager:
i,I'
;'-,
,~
< ..,___,<iLl_.. ).,i
Date: :
Date:
Human Resources:
--,"';<'~'.'
.J
\,.;
Note: TMs ~e_~y~ of Absence Request is not approved until all signature approvals are obtained by all parties, or their-defegates. .
Green: Medical
Canary: HR File
Pink:
< --- ,'----:,
, '-----' -' .
i~~'\fnrrroo:'\I~",-fn'r/-.if1 ;
,,'...;
White> Payroll
, '_"- ,n, ::f: ,__~', _,' _"
, ':',:,~ _',,:f~ '.T';::',~, '
,<:{~;:~':~~~~:;;~; '"
"l!<~IO""-"~llI1g"~I!!!ffi'''''lI!'''''~''''r ~""" , r ,l!"Il!'ilI' I ,- ~
, ~ ,~-~
-
.~-~.- --. ,~~-
~ '.
--"
Request for:
Leave of Absence or Family/Medical Leave of Absence
,,....~-'~..
/'-':,_,- i f' ,-' ,
Name: "';L' .' f 1>,-,' ,....-.
Department: .J- ....,...
Extension: (circle one) NO or ;.'yES
I hereby request Leave of Absence:
Facts ertainin to this leave:
Employee #: Date:
Supervisor: ....~..~/.. ,,'., ./ ..
if Yes, date original iea\@J!Q~?rt' .. , , ..
",'",_-::~'-.~",,'Y-i_W~;--"~.::"',-;, " :'_ '_ '.. :",'_ : ~
(Le., non-FMLA leave,i:ry1hWYty'leave. personal)
'':'::;'"//3 l /; ;<' /
Request leave to start:
Projected return 'to woflfMi\~;~..:;;;
. . -' ~~"",,..,,- -', " ,.
, "':"~1/-~;'-:3;',;,:
I hereby request a Family/Medical Leave of Absence (FMLA) from work for the purpose
My own serious illness, work-related injury/illness
My own serious illness, non work-related injury/illness
Birth of a child or placement of a child for adoption/foster care
Caring for a sick child, spouse or parent
Medical or Informational Facts ertainin to this leave:
x.
,X
;,';EXP~cted due date :
';~~t1[~~~I,~~S::_'!;'~:_:', -', -:;.;:'-:_~;;; ,-: "::\,'-:- .':',' :""-
/
.j!:.~/...r '~~f.:___'" I
1,../ ;i
'. -~>
No iM&6\l'&sri~ed..toc~ref6rilif~l11il member
::__:_-;:'r.--"'."'_:":':': ',:"--- 0-':_' -_-,!'_
Projected retuni'toworkdate::' ~\' ,/ ,;:
"-~_.~---' , ~;t~;~t~~oj:i~~1fS'\,::_>';(o:!:;-:::;:'_~ :~,' ,,~..;r _' ___ <":_'_,' _.. .
Employees on medical leave will provide an Appletof) papers inc., RgfUth,ijto;WoH;Slipsigned by their
doctor or personally provide documentation signed by their doctor toe'~f~D(J;fh~irfeaSie9n.' ' ',.'" '
by 12:00 noon to .'" ,
(Date) (Nam~)
Failure to personally provide documentation to extend this Leave of Absence or failure to rEiturn,to work on the employee's first
scheduled day of work will resutt in loss of seniority (employment) in accordance with,Artjqle,6,6Eof the Labor Agreement. .
. '-: ^ -;\ ' - - ."""';'""<t~~~-i:SX;::;' ,/.:/~t.~~f;:~_<,_;\;>..- ,~-- ';:. ,
Additional Comments:
i ;/
To:
j'"
il-t.:,/"'/-[- :~_,,(d _;~,-,,,,..,.r-#
Employee Signature:
SteWard's Acknowledgement:
i!") ,...,- ~<
1/'/,. <'/ ~/ Date: ':j. '')/- '('1
-":~;l<. ,~.~s,", .",,;:u/\;:,\/\ Date:?4-:Jl-'7fi' ,
/';'~Jf~~,~~!:~;^f~t~>, ':'::-:_'~', :!": ..':, . . .-
'Wi~~l~%j}.,-:::.:": -,:::
Approved by (FMLA ONLY):
-, '~:;"-<';'.'_'
Supervisor:
:. ...".---~._,--~.__.~
Date:
.-:.;::'
''\ ,1 ",; f,
Depart' ',me, nt' Manager'. ;'..1 /L?{(~f.!.,.,\,>,- ,,' / (', /";
. "');''', [late: / > '
Huma"~ Resou.rces:......=s:~.~~,_ ~;~=~~:,:~~e'~:c..... . ",1f~it?;g,~t~::;..~~,-,0::,'~~;.: ..
Note:' .C"~--Th~~,:t~ave-'Of:f~sence RequeSt is not approved uhtil all signature approvals are obtained by a~{ parti~s or their delegates.
'1,';<:";";'.'
Green:
Canary: HR File
_ i~___,.
~:
::~
\.$-:'
!;'i.
il;'
~:
:-'~ffl~fI~II~!mflflfllll1l!!I~llJlI!IIlJ!rolI'f!"II!!.~, ~ _"., ~"
-.-.
'" ,
~---
,
Request for:
Leave of Absence or Family/Medical Leave of Absence
Name:
/c
./ "
Employee #: Date:
Supervisor:, ,"c' "_
If Yes, date originalleailEl;!J~gai1." <{./ '5/0'7
(i.e" non-FMLA leava:~;i;~(iiaW'leave, personal)
Department:
Extension: (circle one) NO or YES
I hereby.~equest Leave of Absence:
Facts ertainin "to is leave:
'....
~-..
Request leave to start:
--------
'---' -', ,'~ ...'.,.."'<- ,-,,""-'} --:.- '
Projected return to wO,.,rk,.;Cli{te:,;" .'.. Y ,
.-- , --
,/ I hereby request a Family/Medical Leave of Absence (FMLA) from work for the purpose
My own serious illness, work-related injury/illness I
My owl) serioys illn~ss"noNN9r~-rEllateg inj.ury/illnjesr _ _ ( ',h',
Birth of a child or placement of a child for adoption/foster care "sjcpectedquedate:
Caring for a sick child, spouse or parenti'~'..;, ',"
Medical or Informational Facts ertainin to this leave:
If a licable Date of illness:
Ph .sician/Health Provider Statement attached Yes or
Request leave to start: 'j/{/ 99 "
Date' ofthe next doctor's appointment: '. I;, ";.' ;.'
Documentation was/~i11 be provided on: Date:,//',/,i ,
"'--'-',>' .
_: _--_,__:':~-,--,"-_, _ :_:'_'-, :,0 _'" , ,'.
No indudes need to care lor ill lamil member
Projected r~tJrht~;"ilO'~k date: .,',' ! "
I -,/- '~f
" ,.~" '. ~ .f , ,!' ,< -f '" _"_'. ._-" , --,'~, __ .__,' _' _
o. _ ' _ ;:':'>~3S~~::'L;:_i;,:~,-:~-t:~::'d} ,>? :"_ _ '__ ',.. , _
Employees on medical leave will providean Appletonpapers Inc. R~ti([rrtd.w()r-k,S/ipsignedby their
doctor or personally provide documentation signed by their doctor toexle'6dthekleave on
,",'j. '. ',. ' 'Y by 12:00 noon to ",<,,"""'" "
" (Date)k ,,',' (Name) ,', " .
Faillir,E! to persori~lIy provide'documentation to extend this Leave of Absence or failure, to relurntowork on the employee's first
sch'Eir:luled day of'~ork will res~1t in loss of seniority (employment) in accordance with ArtJc:le 6,6,E of the, Labor Agreement ,,' ,,'
. -''','-' , --:~, --." ~;--- ___c_.. ',::".S;",-~,'",,'_;;~,',r~;~,_; '/-'-""'-"'(2,.'::_~~-:;~ - - ,-.
-.- "-,'<',"','.,-
, : ::i-~.::;;~j'i~~!i~,Jf:(,%:;{;\\,,;: :1'D".:)
To:"",,;';;,,;,,
>,~-;.-
': ::\;;?iX~~f~~;;.':<~':i'~t;i~:,'
'", -'-", -',
,1':'."','
'Additicfnal C,()intnents':;
'1 ,,_,
, "--,'1
", rif.,
Employee Signature:,,;
.-- :_, ,---~~, - -" -:-
Steward's A~nowled,~elT1ent: f
,~-
,-;
.:< !/
'.' _.'
Date:;;,' " ,11 ' ~
:(~~....-~'
-- ~- ,.
,.~,):j,,}:ig~~7i.,;'
;,/,'./" /' '
C,......l-..~,,-I'.~.~ "-_.LA....../
tt?'
"~!~,,~i~:~~\:::'... ;:~-,," -
Approved by (FMLA ONLY):
Supervisor:
Department Manager:
"r
, l (~/(
Date:.
:i
," -" ~
'--"':'-"
Date,:."
"
'_"";-i:-;.:" ""_1
Human Resources: /'\ ',.~;.t{:j r ! (j \," c" " "<1~~,Ra!~t:5{).,:,:;(j
Note/I}:';;- This Le~~e 9f Absehdft Req!iest is not approved un'iil all signature approvals are obtained b}/~/(j,arljes or their delegates. -,
.~-" ~- . .
Canary; HR File
Pink: Department
, ,- ,
la~ ;\frirm~\loa-formf1- n'
Goldenrod: Employee
-~~"~"'''!!M!I!1'1I'1lfl!lI!'r'l1!!*!l1I~II!~Ilf!'-='''~"'l"r'~~,
.-"
I""",,,_~"~.~U __
('"
;'~f.
-, ',/
, &,,/
Request for:
Leave of Absence or FamilylMedical Leave of Absence
iT /-.~.... -< .~, /} s/19/9C;
Name: i /e C?-<,.,,:::?_LC-C, Employee #:~;~.~l/Date: / - 'i . ,
Department: Supervisor: ;l"iiil'<' ,;<J., /:",.,.-
Extension: (circle one) NO or YES If Yes, date originai leav;~;,;!5~gafr;'.J!R""/ 7 /
>::';::;~~::~:l~'i~,+"'::' ",: '- _ -_ _.. ---'--_~:
I.hereby request Leave of Absence: (Lei, non-FMLA leave, rniJi~tyleave, 'personal)
Facts El'rtainin to:this leave:
.,,~,
.."....,
Request leave to start:
..
Projected return to wofR;B~t~;;_\';
;,'!-,~~;;~~".-" -:", :,-. ,;~
I hereby request a Family/Medical Leave of Absence (FMLA) from work for the purpose
~' Myuwn ~eriousillness,work-related irjury/illness
" :M'~{'oWh'sFeI'i6(!is''iIIIi'E;s''SrRDTfWtrrl{1et&iWTiijurYhlliies-S'' ,;,,', ""'i!""\"'1r,',!,i;,ti"..,'t;,,,,,C,, l
- "" ,- , .. -" ' ~- '.
Birth of a child or placement of a child for adoption/foster care
Caring for a sick chiid. spouse or parent
Medical or Informational Facts ertainin to this leave:
"
-c._:,,;,,_.. ,,".,,_,^_ ,_-_
",',~~,~~"~,~%\;~~,~5~f,;'.:i,i.,
."-'>~~. -- -;- -,. .
1'_,'-'
,t' /'
If a licable Date of illness .~;<,~':;';;;;~":)~~'j"i:;
__ ,-,:_::':"1';::ii;o;-~--::r-\ -,'/": ~""_;:_ ~:-,' .-;_j~--~_ ':",_ ___' _: "_ "_:'--_
Ph sician/Health Provider Statement attach'ed Yes No,/' inc:rti'aes'neeitftdcare for ill famil
- ___ _ -, i~__.___:,:__-'__'- "',:-"_,_-,'-"'-~,: ."_',',,_ ,:'__..:_ -__,--n '
Request leave to start: ,;5 // 1,/9 f " ,'-Projected re{L1r~io\vorkdate:P <
g~~~~:~~~~~t~~~~~'ls b~~Z~~:~~n: '1'7 T(<"':~;}~t~~? .'
, '.: ;.-_~" --::'-,;'j~t.--" - "' -- i}iirt;~~r~;-.-'~::~,};~:_:::tg~~~;.;;:r~:~r:~?~:~fc<~ ,_:-'
Employees on medical leave will provide an\A.ppleton papers Inc. R>;.p.,.t!J(,qt1$M;.~iQq~dby their "
doctor or per,sjo allv g,ro, ViQ, ,e.,s:l" 19Yu, ,m,en,tation signed by their,docto,r toe.=,',",.','"... "',.,!l,'~"..,e,-,m,fJ;,i'"El5:, ,\(;61;'0,.[1,',",,1,;, ."'".,.b,.,.:.,;;.',,':,.,.".
, ',' (Dat~-/ &7 ./ 'l;L, by 12:00 noon to' ,,' (~~m~';~~TS~":':
Failure to personally provide documentation to extend this Leave of Absence or failu~t() returnlo~orkon theemployee~,~ ,first.
scheduled day of work will result in loss of seniority (employm~nt)ini3cGQ(d<lJl.ce INith,t '9 ..' .. he,..LilpqrAgreemebt;'':::'') '.
. --' "~i7:~~i.:i,tS1~~"';,\~/-,i;~;>;.':,-'-. - :
Erilployee Signature:
./ '
/Steward's Acknowledgement:
x
,,'
. - ..
.....~~-"~.,-' -
;;,','-;,-~-":,, .
.' Dat1iit, :;","
~~.,'
~~;~~~~a~~~;~.i~;';\:,>".
i-:,,-: -
Addi1:ioQaliCo'n1m~nts:,
:1'--< ~-',
~_,_;''. k
<<-,'-,
Approved by (FMLA ONLY):
>' /)-..;>T[L'~;r/
,3~,~;r,~,~,~_;~,;,!t.~'~{~.i,:~,;,;J,~~,.,'~,~~,~.,1,:"l~,t.::,~.< '-:'::"':~-'\. ,~:,.- :''', ~ ,--' ',- '
~ - ;,::~~i ,~:r1:~t~i~::~ri)~ c',.." -,--
Supervisor:
Date:
:::..:m:::.:;::.", .... \ :f;" "';;'C~"II~&t&~~~~r~"1
Note: This Lea,ve o,f d:~~~?_~e R~quest;is not approve~ until all signature approvals are obtained'by alfp~rlies'-qr th~i"'d~iegates"
:-, ,---',' " j '-
, ?
Whif~;,f':~Yr8JI.
~'l~~l~~%;i;,' c'
Canary; HR File
, ,~~"'._- "~~~~'ffO'!rl~ffiI], I r ~~-,~rtfl!"'r"'I~ ~~ ~~I '
-~I~ ~..-
, _ ,~~ ~_~"~'"""''''''''''_'''''_~m ...."~,=~,..,"'l"""~~-~"l':~
ir~ ..
'-"
~
,~,,,~
. ~4,
y ~,.-,. 1l
Request for:
Leave of Absence or Family/Medical Leave of Absence
IV
NO or YES
, ,) 1 ~11 '] , I'., ,',
Emplovee #:i" ' Date: "f () ,Ii ~(
Supervisor:
If Yes, date original leave began:
\
Name: i -" \,-i.-v)
Department:
Extension: (circle one)
, ,
it J ,', -,{
(' (. f --t!.v
II hereby request Leave of Absence: (i.e., non-FMLA leave, military leave, p~rsonal)
Facts oertainina to this leave:
" " /
/
J' ,
Request leave to start: I Projected return towork daie:
Yi I hereby request a Family/Medical Leave of Abse~~~ (FMLA) from work for the purpose
" My own serious illness, work-related injury/illness 'j,'
My own serious illness, non work-related injury/illnessl
Birth of a child or placementof a child for adoption/foster care
Caring for a sick child, spouse or paryrt " . .
Medical or Informational Facts ertainin to this ieave:
. , \ --', ".
Exp~cted 'du~date':.
F~"I_ ~
}
/
.,r. ,<
. f'7 1<.t
If a Iicab'le Date of illness:" //'
Ph siik~/Health Provider Statement attached Yes N'o includes need \0 care for ill famil member
Req8esfleave to start:! j",,,f'/:j Projected return to work da~
D~te otthe ne)(tjs,(;;tor's appointment: '!r'I", '-; ,,",'1,"':1/,(' To".. ,;\"" ;.jJ... ,I, .
Documentatio,l:\;'::~Jwill be provided On: .; f f ~ ;r"'f'd L.",,_L- 1\..Ji.'L~,
Employees on medi.cal leave will provide an Appleton papers Inc. Return to Work Slip signed by their
doctor or personally provide documentation signed by'their doctor to extend their leave on '
.,'. , .'
by 12:90 noon to
(Date) (Name)
Failure \0 per~onally provide documentation to extend this Leave of Absence or failure to return to work on the employee's first
scheduled day of work will result in loss of seniority (employment) in accordance with Article 6.6E of the Labor Agreement
I Additional Comments:
Employee Signature:
Steward's Acknowledgement: '
Date: 7, .:: c, "J'?
Pi
<')'
Date: 7", I){
~
,-_.-~..-",.
~....- ,;
.1'
Approved by (FMLA ONLY):
Supervisor:
Department Manager:
",~~~""1 ~'
-' _/',1'
.~-,,~,.,t_,........'
, .
l..:x \.....;:.j~-
_J I ~
'!/L"L,t~)~~.,,(;:; -t....
'~~
Date:
Human Resources:
;,8,:~1-.Jl:~.~,!1 "I
,'}
0('. , ,{ f i.. 'J 'N
Date:
/'J --
~;' .-.
.r- '("I [:7
("""',~ .,.'--:"":'/A.. -;:, ,/
Date:
."/- /1. -01
i .:!y' '.
.~,-,' :;.:..,/ \..!'
Note: This Leave of Absence Reque~t is not approved!lJnti{ all signature approvals are obtained by all parties or their delegates,
\-
White: Payroll
Green: Medical
: HRFile'
Pink: Department
Goldenrod: Employee
':OJ __
.'il"""" ~___ ^",___"",.,_,,,~,~~.
""1
, -~ '~'J"""""
~ ~- l'
Request for:
Leave of Absence or Family/Medical Leave of Absence
Name:
. '(~. ,q ,..1
'l..~.
Employee #:-XC1,:"--' Date: " J,~ L c,;
Supervisor:
If Yes, date original leave began: '.j, 'n' '
(i.e., non-FMLA leave, military leave, personal)
,( <.....
,-
Department: ;_;;; L " i ;
Extension: (circle one) NO or (YES'
I hereby request Leave of Absence:
Facts ertainin to t is leave:
Request leave to start:
Projected return to work date:
I hereby request a FamiIY/lVledicaLL,eave of Absence (FMLA) fromwork for the purpose
..--" """"-.. ,-_:',--"-
V' My own serious illness",vork-related injuiY/illness "
My own serious illness, no'iilNOfk::relafed injury/illness
Birth of a child or placement of a child for adoption/foster care gx'pecteddued'ate:
Caring for a sick child, spouse or parent
Medical or Informational Facts ertainin to this leave:
If a licable Date of illness:
Ph sician/Health Provider Statement attached Yes or
Request leave to start:
Date of the next doctor's appointment: 't. h" 7'>'
Documentation was/will be provided on: Date: 1'-'! f,
No includes needt() care for ill tamil member
Projected'ret,u,r/l to work date:~1f;
.. "
"h
':'I.lv..:j -t,/ ii''- .1<.
'~~~<I To: ..-,~,;t:i':,-J i;--~;~t
Employees on medical leave will provide an Appleton papers Inc. Ret~rf,rq'W~iksfip si~I~~d by their
doctor or.'per~on.?lIy' provide documentation signed by their doctor to extend>t~~irleCl"e6n>< '
't [:, {1 c; by 12:00 noon to' ',.'.,"'. '...,.'",. .,.'" '
(Date) ",' ' (Name)'"..' '.,' '.',' ", '
Failure to personally provide documentation to extend this Leave of Absence or failure to return to work on the employee's first.
scheduled day of work willresult in loss of seniority (employment) in accordance withArticle6,.6E of the Lab()rAgreement .
. ,-~ -\-,
I Additional Comments:
Employee Signature:
Steward's Acknowledgement:
- ,.-.
I
, ,
Jj~~fi_~ -~V'"_/
/1 / i ..<--,.
C:::J\:~/:;,,__:>/~"/' /
, pate:V.'.:.t:f
M"
~~
,
" ",,'''Y',.,., y/
Da'te""/<';';' '/"I'
.""'. (',',;", ;.
Approved by (FMLA ONLY):
"'-~-~~
'\~......._'"......./'
Supervisor:
Department Manager:
Human Resources:
<;;~-'~!~~-
~.~;'~., '-) ('_~J. j,V---
" ",~J~:~..S::d____
f
)
Date:
I~"" - (
?r-.,-/ ,,X
.. - ( ~~
I..!~ ~;
~
Date: .
Date: '
Note: This Leave of Absence Request is not approved until all signature approvals are obtained by a!i pa:fties or their de/egat~s. '
White: Payroll
Green: Medical
Canary: HR File
Pink: Department "
, . .
, h~:"~~~~""'" ',,-~"';'H'-
~*': ~pr<""~'1!""-.>~:"'"~ ~~
11111I'1 I
~, - ,
~
_~"'1
""""'--
Request for:
Leave of Absence or Family/Medical Leave of Absence
t ~-.-
'" j Tr~"
Name: .-!-.(." iL' . ,-" <r !'i<C_"
D rt t i l._
epa men: I -c.~
Extension: (circle one) NO or(YES
I hereby request Leave of Absence:
Facts ertainin to this leave:
C}i "
Employee #:,.)(,,2 ] Date: / ,',' /
Supervisor:' '_".
If Yes, date originai leave began:
(i.e., non-FMLA leave, military leave, personal)
// ./"
0'." '
Request leave to start:
Projected return to work date:
-',; ,>'.
-".-,
I hereby request a Family/Medical Leave of Absence (FMLA) from work for the purpose
My own serious illness, work-related injury/iliness
My own serious illness, non work-related injury/illness " 'n" , " ,
Birth of a child or placement of a child for adoption/foster care, ExpeGtEidduedate:
Caring for a sick child, spouse or parent " "
Medical or Informational Facts ertainin to this leave:
If a licable Date of illness:
Ph sician/Health Provider Statement attached
Request leave to start:
Oate of the next.9,Qctor's appointment:
Dbcumentation~jlwill be provided on: Date:
Yes or
member
9, .1'-. $19
.
,. ,,-, ,Co~, _.;r r,
I Additional Comments:
Employee Signature:
Steward's Acknowledgement:
,._C."_. _""
'/;"'-'-":'
:':-:-,-" --'-
,,-, ,,:,.;~;-{-' ;,' .- -."!:
I} -r"'"
)<:i!<<--~~7
c"*di" C::c:; ,fc:r.c(')
....
,:e'J'. ';,__:_-;__::::\.-'.";
,.',
o~i~{;1': 'j:?,'; ,
.-;. ~~- :bat~~':-:f1:;li:~::'~l~f
-,-,.',--'-- -,'
-' ",--,,:-,'~_~_::-'~g';2\'r-'i.. ;',1-->:' -,' -
',~'
Approved by (FMLA ONLY):
Supervisor:
Department Manager:
Human Resources:
Oate:
':Oate:
.-,-".
,Da!e:,.
Note: This Leave of Absence Request is not C!Pproved until a/1 signature approvals are obtained by all parti~s- 'or thei; delegates.
:'~1I'll'T J._",,,,,~~~~.
~~ - 1'l!Il!,- I
~ ., I
'''i''''~
, White: Payroll
Green: Medical
Canary: HR Fi,le
I~
?~~""..~
"""..........,..,,'~1i"!iOll'~-
.ilr'...,',., v
: - III
/
"
,I
,
FG"qdi~ s,t ,:,(';...
Leave of Absence {lr FmuHril'\!'kr'llcJi L:~;;:I,,<m of Absf,mce
,
t,lall)~.:__ ~c.L&'d<'i-.:::-__s:i~~~jl~==<_" ',,'_ ",. Lflll;oi'2i~", #";'/i,,,'~'I)~t<:).~~<;/lif" ~_
d~i~~~~~1"~~i'Cle;~e)"-'~N~1 ~;li~~:::'iXc:.~'~18If;,'~~@i~~Ji~{~~E.1J~~~~-'~~~~:~
i f~:;:~"~~~:;~ ~:::~ of Ab'''''''',,'"O'''',"LA I",,,: milit", ",:,p~:",ij__ ..~
t'~(~I8~~~~,;~~-t~~~~~~-"~~~~--' - -.~- '-,--- -,~6'1~~,~:;t,;~~e~~;~~~-~~~;~-'(~;~,~_-:-_:-~>~~:"'~:-::::> -.. l
r- Y.~-lhere-bY -;;~~(~st-;F-;mily IM~di~;ll~~;~~i~A-I;~';~~;;;~'\FIi';L II) f;~"~;~~',;-;kf~-rth;'-~;u rpo~~
'-''''1 My own senous Illness, work.related Ir'Jurylillnf~s'
I--I~_' My own serious Illness, non work-related 1I1Jury,'d! less
Birih of a child or placement of a child for adoptl(;n/'oster care Exp€\Gtnd due dati;:
L_ _--,
I_....._.! Caring for a sick child, spouse or parent
I f@gi~.E1Ql:lnforJnational Fa(:ts pertaining tgJill;;J\l.9:,,:Ii:n._____nn____
IkJpplicable) Date of illness: ....___..____._______.__.____..n....______________.
Phvsician/Health Provider Statement attached Yes or No -,-'''clude" """ci 10 care lor ill family member
lX~~;~;esi le;~~: to start ~-----~=Jp~(;~.~t~~~~~t~~2; -tc~~;~~kd~t~-~--$)~ . /?
Date of the next~tor's appointment: ~,,-y" 0 I1J 1ft
DCCl)lIlentatlon~WIII be provided on: Date: ~Jl;/-~//l-fL----' To: /CL__'~b~=-
Employees on medical leave will provide an Appleton papers tne fr:elu!IJ to Work Slip signed by their
doctor or personally provide documentation signed by their doctor to extend their leave on
by 12:00 noon to ..._._________________.__
(Date) (Name)
Failure to personally provide documentation to extend this Leave ot Absence or failure Ie ""Ill"', to work on the employee's first
scheduled day of work will result in loss of seniority (employment);n accoroance l'Ii,h ,\rl'ci" 6,6E ofihe labor Agreement
~:;::~:,::~:,:m-----< it: ~~~~~~_-_~~:~=~- T ~.
S+'eward's Acknowledgement:
Ca'te-:
--.~...."'..'-_._.__...-_._.._.._...."'---_............._g-~._"._-,,~_....,..........~".,.......,........,...,....".....,,,....,,..-g_....'""'_.._,,.,,",..,,.....-.,
Approved by WMLA ONLY):
,-~---_.- - -.__.~....' -.____...,..,...._... ___ ..--~ ,___,..', __".'W_"'__"__^ ..,__
Supervisor:
---~-------,-------'..,-^-_..._-'.._...,"
iJaie:
D.!~p"ltrn'~nt Manage,/,:
Human I~esources:
Date'
Date:
Note: fhi5 Lflave c,( Absence Request IS not approved until aIJ signature il,::Jprova/s .am ot,f,'lit1l~d iJ~' ati pa,tie-s or tlleir deJega~~J$,
[~;,~~it~~P~~:~~:I~=-~I Green "Me~lcal" ___Tc;~~~~I:;R~~~=-~T~!:~~~;~~~~:~,,~_~~.:I~,0,,~~~=~~PI;;-~
:i',~' \.form~;\.::-;;,(orm!l
:- h,""" :"~-. '.
J ,,^ -
T!'"",
, ~-"
.
COMMONWEALTH OF PENNSYLVANIA
,
DEPARTMENT OF LABOR AND INDUSTRY
Bureau of Workers' Compensation
_ - - - - - - x
In the Matter of:
Dean Teeter,
Claim No, 2051428
vs. Penalty/Reinstate
Claimant
Appleton Papers, Incorporated,
Defendant
_ _ _ _ _ _ _ - - - - - - - x
Pages 1 through 36 Hearing Room A
Harrisburg Judges Office
East Gate Center
1010 North Seventh Street
Harrisburg, Pennsylvania
Thursday, February 22, 2001
Met, pursuant to notice, at 2:30 p.m.
,
BEFORE:
KARL H. PECKMANN, Judge
APPEARANCES:
JASON P. KUTULAKIS, Esquire
8 South Hanover Street
Carlisle, Pennsylvania 17013
(For the Claimant)
ROBERT J. GODUTO, Esquire
Fifth Floor
305 North Front Street
P. O. Box 1003
Harrisburg, pennsylvania 17108-1003
(For the Defendant)
Commonwealth Reporting Company, Inc.
700 Lisburn Road
Camp Hill. Pennsylvania 17011
.
(717)761.7150
1.800.334.1063
--!!;~
,-,
,
" II l.
,
I
I
r
f
i
I
!
I
,
i
I
I
i
,
~
..
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
I
19 I
20 II
21 Ii
22
23
24
25
17
the decision not to come to work.
BY MR. KUTULAKIS:
Q Under the union regulations, is an accepted leave of
absence defined?
A Yes, it is.
Q Okay. Was he on an accepted leave of absence under
those regulations?
A
Based on -- based on the union contract, yes.
MR. KUTULAKIS: Nothing further, Your Honor.
JUDGE PECKMANN: Anything else?
MR. GODUTO: Yes.
CROSS-EXAMINATION
BY MR. GODUTO:
Q Mr. Honafius, in terms of the documentation that was
submitted by Mr. Teeter for a requested leave, when were
the last time those documents were completely filled out to
continue the leave?
A The leave of absence form was filled out completely
on July the 26th, and that leave was signed off by his
supervisor, department manager, and human resources.
Q What's required internally -- first of all, what's
required to have an approved leave?
A Ah, to get the approved leave of absence, the
employee must present medical documentation that they have
a disability or are unable to perform their job, and they
COMMONWEAL3"H-REPeR-T-ING COMPANY (717) 761-7150
'"'
~OC J;orm 161-B (10/96)
U.S. EQuAL EMPLOYMENT OPPORTUNITY COMMISSION
NOTICE OF RIGHT TO SUE (ISSUED ON REQUEST)
To:Dean A. Teeter
1605 Walnut Street
Camp Hill, PA 17011-3971
From: Equal Employment Opportunity Commission
Philadelphia District Office
The Bourse
21 S. Fifth Street, Suite 400
Philadelphia, PA 19106-2515
On behalf of person(s) aggrieved whose identity is
CONFIDENTIAL (29 CFRii 1601.7(0))
170A10385
EEOC
Representative
Stanford Lamb. Investigator
Telephone No.
Charge No.
2[5-440-2617
(See also the additional infonnation attached to this fonn.)
NOTICE TO THE PERSON AGGRIEVED:
Title VII of the Civil Rigbts Act of 1964 and/or tbe Americans witb Disabilities Act (ADA): This is your Notice of Right to Sue, issued under Till
VII andlor the AOA based on the above-numbered charge. It has been issued at your request. Your lawsuit under Title VII or the ADA must be file
in federal or state court WITHIN 90 DAYS of your receipt oftbis Notice. Otherwise, your right to sue based on this charge will be lost. (The
time limit for filing suit based on a state claim may be different.)
[X More than 180 days have passed since the filing of this charge.
[
Less than 180 days have passed since the filing of this charge, but 1 have detennined that it is unlikely that the EEOC will be abl
to comp[eteits administrative processing within 180 days from the filing of the charge.
X ]
]
The EEOC is tenninatiDg its processing of this charge,
;-<'
The EEOp \viii continue to process this charge.
Age Discrimination in Employment Act (ADEA): You may sue under the ADEA at any time from 60 days after the charge was filed until 90 days
after you receive notice that we have completed action on the charge. In this regard, the paragraph marked below applies to your case:
The EEOC is closing your case. Therefore, your lawsuit under the ADEA must be filed in federal or state court WITHIN 90
DAYS of your receipt oftbis Notice. Otherwise, your rightto sue based on the above-numbered charge will be lost.
The EEOC is continuing its handling of your ADEA case. However, if60 days have passed since the filing of your charge. you
may file suit in federal or state court under the ADEA at this time.
Equal Pay Act (EPA): You already have the right to sue under the EPA (filing an EEOC charge is not required.) EPA suits must be brought in
federal or state court within 2 years (3 years for willful violations) of the alleged EPA underpayment. This means that backpay dne for auy
violations that otcurred more than Z years (3 vears) before you file suit may not be collectible.
If you file suit based on this charge, please send a copy of your court complaint to this office.
On behalf of the ~n
~ ~,l~~~
\- n-t>\
Enclosure(s)
Information Sheet
Marie M. Tomasso, District Director
(Date Mailed)
cc: Appleton Papers, Inc.
JasOll P. Kutulakis, Esquire (for Charging Party)
-"~'IlW.I,
"
-~-
-,-"
'1 I ~,
_,,_!IIIIIIMIl!lllI
SHERIFF'S RETURN - REGULAR
CASE NO: 2001-02217 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
TEETER DEAN
VS
APPLETON PAPERS INC
GERALD N. WORTHINGTON
Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
APPLETON PAPERS INC
the
DEFENDANT
, at 1425:00 HOURS, on the 18th day of April
2001
at 2850 APPLETON STREET
MECHANICSBURG, PA 17055
by handing to
JAMES HONAFIUS, HUMAN RESOURCE MANAGER
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing His attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
18.00
8.68
.00
10.00
.00
36.68
~ ;",,'
.!" 0<\3'
, ,.."..,.~~'-~" :'''- "
r:i ~ -7 __"""'C'<"'"
R. Thomas Kline
04/19/2001
ABOM & KUTULAKIS
Sworn and Subscribed to before
BY:~ ~
~I ..
Deputy eriff
me this 2ft,(~ day of
A.D.
,
C:~<J(~/ '
.;]
9 ,t~ ~-~~,r:_Il!R1" _,
""""'1~'T .
-
"
, ~ .. :'J.-
Plaintiff
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
DEAN TEETER,
v,
: CASE NO.: 01-2217 Civil
APPLETON PAPERS INC.,
Defendant
NOTICE OF FILING OF NOTICE OF REMOVAL OF ACTION
TO THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYL VANIA
TO: THE PROTHONOTARY OF THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
--and--
COUNSEL OF RECORD
In compliance with 28 U,S,c. ~1446(d), you are hereby notified of the filing of a Notice
of Removal of this action to the United States District Court for the Middle District of
Pennsylvania, A copy of the Notice of Removal is attached as Exhibit I,
Respectfully submitted,
DUANE, MORRIS & HECKSCHER liP
rine E
t rney 0.4129 '
obert J. Goduto, Esquire
Attorney ill No. 55769
Jennifer L. Murphy, Esquire
Attorney ill No. 76432
305 North Front Street, 5th Floor
P,O. Box 1003
Harrisburg, PA 17108-1003
Attorneys for Defendant, Appleton Papers Inc.
HBG\74791.!
~-K:.'_"'"""'1~" ',,~, ,_.",_",' ,
1 '1-1
",
,
"
DEAN TEETER,
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
.1 : ell ...
Plaintiff
~J 1 = Or, 80
FlLF9
HARRISBURG, PA
v.
CASE NO.:
:~~ t--C,
Defendant Y I I
MAY 0: 2001
APPLETON PAPERS INC.,
-,,~-
NOTICE OF REMOVAL
Defendant Appleton Papers Inc. ("Appleton"), by and through its counsel, Duane, Monis
& Heckscher LLP, hereby files this Notice of Removal of this action to this Court and states as
follows:
1. Appleton is a named Defendant in a civil action in the Court of Common Pleas of
Cumberland County, Pennsylvania, docketed as Dean Teeter v. Appleton Paoers, Inc., No. 01-
2217 Civil (the "State Court Action").
2. The Complaint in the State Court Action was filed with the Prothonotary of the
Court of Common Pleas of Cumberland County, Pennsylvania on April 16, 2001.
3. Appleton was served with Plaintiff Teeter's Complaint on April 18, 2001.
4. In Count II of his Complaint, Plaintiff Teeter asserts a claim under the Americans
With Disabilities Act, 42 U.S.c. ~ 12000 et seq.. a federal statute.
5. In Count III of his Complaint, Plaintiff Teeter asserts a claim under the Family
and Medical Leave Act, 29 U.S.c. ~ 2601 et seq., a federal statute.
6. This Court has subject matter jurisdiction over this action pursuant to 28 U.S.c.
~ 1331 because it arises out of the Constitution, laws or treaties of the United States.
Accordingly, this action can be removed by this Court by Notice pursuant to 28 U.S.c. ~1441(b).
;'-'-,J__,
- ~ _ -~-l ~
1-1-
'f~,:4~~,_~-<- _
",
7. This Notice is being filed within thirty (30) days after Defendant Appleton
received a copy of Plaintiff Teeter's initial pleading setting forth the claims for relief upon which
Plaintiff Teeter's action is based.
8. This action was commenced within the judicial district and division of the United
States District Court for the Middle District of Pennsylvania. 28 U.S.e. sI441(a).
9. Copies of all process, pleadings, and orders served upon Appleton in the State
Court Action are attached hereto as Exhibit A.
10. Promptly after the filing of this Notice of Removal, Appleton shall give written
notice of the removal to the Plaintiff through his attorney of record in the State Court Action and
to the Prothonotary of the Court of Common Pleas of Cumberland County, Pennsylvania, as
required by 28 U.S.C. SI446(d).
WHEREFORE, Defendant Appleton Papers Inc. respectfully requests that the above-
described action pending in the Court of Common Pleas for Cumberland County be removed to
this Court.
Respectfully submitted,
DUANE, MORRIS & HECKSCHER ILP
alters,
rney No. 4129
Robert J. Goduto, Esquire
Attorney ill No. 55769
Jennifer L. Murphy, Esquire
Attorney ill No. 76432
305 North Front Street, 5th Floor
P.O. Box 1003
Ranisburg. P A 17108-1003
Attorneys for Defendant, Appleton Papers Inc.
BG\74786.1
'"
~- '.
1'1
" -,.
.
"
, ,.
jJ OJ - cJ. d- I 7
"'-
{j~~~
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this Complaint and Notice are
served, by entering a written appearance personally or by attomey and filing in wriring with the court,
your defenses or objections to the claims set forth against you, You are wamed that if you fail to do
so, the case may proceed without you and a judgment may be entered against you by the court without
further notice, for any money claimed in the Complaint or for any other chUm for relief requested by
the Plaintiff. You may lose money or property or other rights important to you,
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Lawyer Referral Service
1 Liberty Avenue
Carlisle, Pennsylvania 17013
(717)
/l-d I 1//
/VC Illf/r:f'/
~
:'i'__r.
, ,-
-
,.~
r<-"I'
,
.'
"
NOTICIA
Le han derrulQdado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas
en las paginas sigiuentes, listed tiene veinte (20) dias de plaza al partir de la fecha de la demanda y la
notificacion, Usted debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en la
corte en forma escrita sus defensas 0 sus objeciones a las demandas en contra de su persona. Sea
avisado que si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin
previo aviso 0 natilicacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda.
Usted puede perder dinero 0 sus propiedades 0 otros derechos importantes para usted.
llEVE ESTA DEMANDA A UN ABOGADO INMEDIATEMENTE. SI NO TIENE
ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA
EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE
ENCUENTRA ESCRlTA ABAJO PARA AVERlGUAR DONDE SE PUEDE CONSEGUIR
ASISTENCIA LEGAL.
Cumberland County Lawyer Referral Service
1 Liberty Avenue
Carlisle, Pennsylvania 17013
(117)
?;j,~
~.~,
~-1" c
""'Irr
"
"
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
DEAN TEETER,
v,
CIVIL ACTION NO.: 01- c1J.17 ~:cL
APPLETON PAPERS, INC.,
Defendant
: JURY TRIAL DEMANDED
COMPLAINT
1. Plaintiff, Dean Teeter, is an individual who resides at 1605 W:tlnut Street, Cliffip Hill,
Pennsylvania, 17011.
2. Appleton, Appleton Papers, Incorporated, (hereinafter "Appleton") is a corporation
organized, operating and existing under the laws of the Commonwealth of Pennsylvania, which has
its local place of business at 2850 Appleton Street, Mechanicsburg, Cumberhnd County,
Pennsylvania 17055.
3. At all times relevant hereto, plaintiff was employed in a second-hand operator's position
at Appleton's Mechanicsburg, Pennsylvania plant.
COUNT I
WRONGFUL DISCHARGE
4. The allegations contained in paragraphs one (1) through three (3) of this complaint are
incorporated herein by reference as though fully set forth.
5. On or about April 7, 1986, plaintiff became employed by Appleton. He held his current
position as a second-hand operator position for approximately thirteen (13) years.
6. On or about March 3, 1999, plaintiff injured his left arm, elbow and hand, while in the
course ofhis employment
7. As a result of the March 3, 1999 injury, plaintiff received surgical intervention on April
12, 1999, by Appleton's panel physician, Dr. Robert J. Maurer.
8. Plaintiff received a re-graphed nerve followed by eight (8) weeks of rehabilimtive therapy
prior to his return to work.
9. Appleton accepted plaintiffs accepted workers' compensation claim as a result of the
March 3,1999, injury. The period of accepted workers' compensation was March 3,1999 through
July 5, 1999.
'-'f!,"~1? ,
0,
"~
~~1 I"
~.~
10. On or about July 5, 1999, Dr. Maurer instructed plaintiff to return to his pre-injury work
position.
11. Following his return to work, plaintiff began experiencing numbness, pain and
aggravation at the surgical point in his left arm. He reported these problems to his supervisors.
12. On or about July 27, 1999, plaintiff obtained a second opinion from his own physician,
Morton L. Rubin, M.D., F.A.C.S. Dr. Rubin is an orthopedist.
13. Dr. Rubin directed plaintiff not to return to the pre-injury work position.
14. Dr. Rubin is of the opinion that plaintiff has sustained a repetitive work injury.
15. Dr, Rubin approved plaintiff for work in any position not involving repetitive motion
with plaintiff's left arm.
16. Appleton was advised of Dr. Rubin's instruction for plaintiff to return to light duty with
nO repetitive motion of his left arm.
17. Appleton refused to provide any light duty work for plaintiff.
18. On or about August 3, 1999, Appleton informed plaintiff that they would not be
accepting his workers' compensation injury claim.
19. On or about August 5, 1999, plaintiff filed a Reinstatement Petition for workers'
compensation benefits.
20. On or about August 18,1999, Appleton filed an Answer to plaintiffs Reinstatement
Petition. Once again, Appleton denied his requests.
21. Appleton has never offered plaintiff light duty work.
22. Plaintiff followed Appleton's procedures for medical leave and completed all requisite
forms necessary for leave,
23. On or about October 25,1999, Plaintiff's name appeared as having been terminated and
was displayed at Appleton on the employee status bulletin board. (See, Finishing Department
Schedule 25 October 1999, attached hereto as Exhibit A).
24. Appleton fired plaintiff on November 2, 1999.
25. Plaintiff was on an accepted leave of absence on November 2, 1999.
,"ll _ ,__~
~--
I I
-,
.
26. Appleton knew that plaintiff was on an accepted leave of absence when they fired
plaintiff. (See, Request for Leave of Absence or Family/Medical Leave of Absence forms, attached
hereto as Exhibit B.)
27. Appleton's human resources manager, James A. Honafius, testified at a union grievance
hearing and workers' compensation hearing that plaintiff was fired while on an accepted leave of
absence. (See, Notes of Testimony from Workers' Compensation Hearing on February 22,2001,
page 17, attached hereto as Exhibit C).
28. Phintiffs termination by Appleton violates public policy, was in violation of Appleton's
legal and ethical obligations and was intended to punish plaintiff for filing for workers'
compensation.
29. 'The conduct of Appleton, acting through its agents, servants, workmen and/or
employees, as set forth in this Comphint, amounts to a wrongful discharge of plaintiff.
WHEREFORE, phintiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00, plus interest, costs and attorney fees.
COUNT II
VIOLATION OF THE AMERICANS WITH DISABILITIES ACT
31. Phintiff incorporates by reference the allegations in paragraphs 1 through 30 as though
set forth herein.
32. Phintiff has exhausted his administrative remedies and been granted a Right to Sue
letter from the Equal Employment Opportunities Commission (EEOC). (See, Right to Sue letter,
atalched hereto as Exhibit D).
33. Phintiff is mentally/physically disabled as defined by the ADA.
34. Phintiff is a qualified individual with a disability within the meaning of the ADA.
35. Appleton discriminated against plaintiff because of the disability.
36. Appleton tenninated phintiffbecause of his work-related injury.
37. Appleton's tennination of phintiff is a discriminatory action prohibited by the ADA.
38. Appleton's discriminatory conduct as to phintiff was taken with malice with reckless
indifference to the federally and state protected rights of phintiff.
"z,^
1.-
.
~ ~1~ ,
, ~~
39. Appleton's termination of plaintiffs employment has caused, continues to cause and will
cause plaintiff to suffer substantial damages for future pecuniary losses, mental anguish, loss of
enjoyment of life, and other non-pecuniary losses.
WHEREFORE, Plaintiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00. This demand is for all wages lost since November 2,1999, through the
present, interest on all wages lost since November 2,1999, to the present, future pecuniary losses,
mental anguish, loss of enjoyment of life, and other non-pecuniary losses, and costs of this action,
including expert witness fees and attorney's fees.
COUNT III
VIOLATION OF THE FAMILY MEDICAL LEAVE ACT
40. PhUntiff incorporates by reference the allegations in paragraphs 1 through 39 as though
set forth herein.
41. Appleton employed more than fifty (50) employees at the location where the plaintiff
worked.
42. Plaintiff worked in excess of 1,250 hours at Appleton's place of business in the twelve
(12) months preceding his request for leave under the Family and Medical Leave Act, hereinafter
referred to as "F1\1LA."
43. On September 8,1999, PhUntiff requested leave under the FMLA, 29 U.S.CA. ~2612.
PhUntiff was unable to perform the functions of his position due to his health condition.
44. On October 4,1999, PhUntiff requested leave under the FMLA, 29 U,S.CA. ~2612.
Plaintiff was unable to perform the functions of his position due to his health condition.
45. Appleton denied phUntiffs requests for leave under FMLA.
46. Appleton never requested nor required plaintiff to obtain certification issued by his
health care provider, as permitted pursuant to 29 U.S. CA. ~2612.
47. Appleton denied plaintiffs exercise of rights provided under the FMLA.
48. Appleton discharged the phUntiff due to his repeated requests for leave under the
FMLA.
49. Appleton's firing of plaintiff is in violation of the FMLA.
WHEREFORE, PhUntiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00. This demand is for all wages lost since November 2, 1999, through the
n_
"-,1,,,
"""'1'1
.- "
:_~,,--~~~"
"
present, interest on all wages lost since November 2, 1999, to the present, liquidated damages in an
amount equal to plaintiffs lost wages and interest thereon from November 2,1999, to the present,
and costs of this action, including expert witness fees and attorney's fees.
COUNT IV
INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS
50. Plaintiff incorporates by reference the allegations in paragraphs 1 through 49 as though
set forth herein.
51. Appleton's conduct in firing plaintiff while on an accepted leave of absence and a work-
related injury, was extreme and outrageous.
52. Appleton's conduct intentionally caused plaintiff emotional distress.
53. Appleton's conduct was with the reckless disregarded for causing plaintiff emotional
distress.
54. Plaintiff has suffered severe or extreme emotional distress as a result of Appleton's
conduct.
55. Appleton's conduct caused plaintiffs emotional distress.
WHEREFORE, Plaintiff demands judgment in his favor and against Appleton in an amount in
excess of $25,000.00 plus interest, costs and attorney's fees.
COUNT V
56, Plaintiff incorporates by reference the allegations in paragraphs 1 through 55 as though
set forth herein.
57. The conduct of Appleton, as more fully set forth above, was outrageous, intentional,
malicious, willful and in blatant disregard for the rights of plaintiff.
58. As a result of said conduct, Appleton is liable to plaintiff for punitive damages.
WHEREFORE, Plaintiff demands judgment in his favor and against Appleton in an amount
in excess of $25,000.00 plus interest, costs and attorney's fees.
f2.t sD:=:'C.-T I-UCu/ S/.I.JY1J' TT~
~ l~wI~j
7~'i{1
~ '(pWi{ JI~ t-e K.. S /-:
1P..!1/U..L.j (j;; ,'7/9 / -z..,g
- / '
-","',
f"""', r
CERTIFICATE OF SERVICE
AND NOW, this 16th day of April, 2001, I, Jason P. Kutulakis, Esquire, hereby certify that I
did serve a true and correct copy of the foregoing ENTRY OF APPEARANCE AND
COMPLAINT ON BEHALF OF PLAINTIFF upon all counsel of record by depositing, or
causing to be deposited, same in the U.S. mail, postage prepaid, at Harrisburg, Pennsylvania, addressed
as follows:
By First-Class Mail:
Robert J. Goduto, Esquire
Duane, Morris & Heckscher, LLP
305 North Front Street, 5th Floor
P.O. Box 1003
Ha.rrisburg, PA 17108-5500
~~
Jas n P. Kutulakis
:,.r
--",>
-T,
~-
DEAN TEETER,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
CIVIL ACTION NO.:
APPLETON PAPERS, INC.,
Appleton
: JURY TRIAL DEMANDED
ENTRY OF APPEARANCE
Please enter the appearance of the undersigned as counsel for Plaintiff, Dean Teeter, in the
above-captioned matter.
Respectfully submitted,
ABOM & KUTULAKIS
Jason . Kutulakis
Attorn yLD. 80411
8 South Hanover Street:, Suite 204
Carlisle, PA 17013
Attorney for Plaintiff
Dated: ~-J&-o I
;,,;" -, .~ ~ ..
-"f'-,'
"p'
CERTIFICATE OF SERVICE
AND NOW, this 16th day of April, 2001, I, Jason P. Kutulakis, Esquire, hereby certify that I
did serve a true and correct copy of the foregoing ENTRY OF APPEARANCE AND
COMPLAINT ON BEHALF OF PLAINTIFF upon all counsel of record by the method listed
below:
Cumberland County Sheriff:
Appleton Papers, Incorporated
2850 Appleton Street
Mechanicsburg, P A 17055
First-Class Mail
Robert J. Goduto, Esquire
Duane, Morris & Heckscher, LLP
305 North Front Street, 5th Floor
P.O. Box 1003
Harrisburg, PA 17108-5500
,,-""""
" ,
~~ " I
-
"
~
0'
...
:;1
41
:Q
"
'...
~
o
(l
:'/
+l
.J
51
llli
~ f
51
;:;; I
gs
<"
"-
~
~
X
III
~
... ,
~.......;~..,~ ....
, ! I
Ii 11 I i
~ ~ .,.;
. ~ I i;iiiilli i
:"!'l ~:! q "! q
-~ ~-
-
e ~
~ ; HnHU j
i .~
II::
. :; '" a; , l'l ~ 2
~. ~ ~ ;. ~.;:
" ;f!!
i I - ~
~ ~ i~ i.; i
~i:~;~~~ffi E~!I!o ~!
$ ;"~~l& ~ t? -i! ~ l
~ j lS c :s -:Ii 5.. ~i
~ 1~ i i II
i
I
I
%
- ~
...... ,.
i !~.IUO
ii!~ ~1Cl>mU
th
i Huau I
i;i
SEE i ~
~ fi";; . IlcD."
C " Ii
~ ~j i G -~,!: Iii I fit .. ~
~ .. ;.. ;... fH i..... '
ill U 11 . fit,~ j Ii ~.11ll QII~ h ~ I H cg t
;i~lii .. Iii ~ ~t ~
eiIS:. ila ~
j 1..,~,.I.ill. :.;'.;I",~. illl.if a5gaCD 0;
2'~~al~~ t; ~ -.- I ~
~ iiS~!~ ~~ ~ '
.. 2~~q~= q~~. ~
~ i~E~R ~~ ,
~!n
b", "
"~"i1~~~~_~~~_, 11!!>..'F:, ----r --I - '~I
~ ~ ~ ~ I ~_~."""..~.~~.
, (1,J...~ \~i! .
. ,_ I,
Request for:
Leave of Absence or Family/Medical Leave of Absence
:...) 1 .'
, 0/3/' (:
Date: I ;:; /
----:--- , ,
/ p e .i:.,Jc/ .
Employee #:
Supervisor: "S/;"lk4.!!.;"/,,', ","
.If Yes, date original leave began: _ ' ~/ d / $I /.'
(Le., non-FMLA leave, military leave, personal);
.[2e 11.-,.'
Request leave to start:
Projected return to wClrk'daW{.
./
"
- J
Approved by(FMLA.ONL V): ..." '
Supervisor: ..,',.. '~:~
Department Manager: ;R. if 1"
>:'(,:~'~~'/;}d.0-{>'~~:'.P,:~$''; - ,
Gieen;;~@l<:.al~i{!t~\';~! :'C~narY:" HR File. ,..., '
:: ~. ,~:?,,:':;:7 ~~t;r~::'~-"5(:i~%'t\\.~. '.' " '-: ---'-': ." - ':. . :' i.' '> ,-~:i: (,,_~:~/ )~,~~~J, ~::~<,~f~~;t/1( .;:::~ ;ri.~,,~~~-:.;\)~;~0::),:#:,:\~~,~~.:;~Jl-;~~)~~''-;'~
"""","-ii""'-~'~~'IIIr~llmlfll~~~"" 1~_"1"~.or'r.1lJIJ>J!"'~~", ~ " "".. 'f"'''''''''''''''""
n~mfJl~IIfI"'lmlll_IIIIIIIIIl!IlI.1U
--
~m~"lI!mt1<Jl~
Request for:
Leave of Absence or Family/Medical Leave of Absence
Name: \C <.-'L!A._ ~~:{t. v~t..~'\,_,..-/
Department: i" ":,
Extension: (circle one) NO or ,YES}
I hereby request Leave of Absence:
Facts ertainin to this leave:
.5/",
Emplo~ee,,#:):~~' 1 Date: /,' '"" ,
S u perv IS. 0 r:: ,-;_).',;,;~:", '. '::', ,:.
If Yes, date originalleave,beg2\n:Y..".
. ' , '. . ' .~ "",' ",,:' ,_'r ~"-.::;- . ,....,'....', ;,,'_ ,., _ _ { :' ',~-.," ". -
(i.e., non-FMLA leave; militaN lEi<iiie,'personal)
_ ' - . - ..-" ,: "\':,~.;.:'~;_'.;;~> _~Ct:; ~:"~;' ~::" .:'.-. '_ - _:.. ':, :::~_..-
;.- .
'~" '
Request leave to start:
Projected' return towdt~:~~(~~\f;;~:::::;;i,f:.
, .
Employee Signature: :
, -.' ---, - '--'.'
, . '
- . , . ,
Sieward'sAi:knowledgem~nt:
/' -'., .,~, ~-',:. -,' . .". ',:-
Approved by (FMLA O~: _ :, .,,} 'J "" ,.,."
Sl!perv.isor:. C;,{ 71 /ry- j ,{ (..-~:' "
Department Manager: I'? ~l'}i;.~J;,.!~-;(
- . :.,;:,::'J).> ' , ~"r\1'
Human Resources:, ~2,--;'
~.l~~'
t-'~l'l'l!-m!"'ilt1~1@tt~WI"'lI'I"l!lffl1[!11II~~IRlIi1I(~~
~I '1 "~,
~r'
-~-r '
t"....,
,~~_llllfllflll!m!Jlftlftlllt!lm~""_~_IIIIIlI;J1Q~"'lI'IlII~<1_"''''''''''''''''"'"''''"1'<~'Fi''~
-.'!
,~ ~- . "
Name:
Request for:
Leave of Absence or Family/Medical Leave of Absence
.. - .
, ,
--
~ , ',. -- '
Ie, ." J' ," /
y , - f"-__".---"
;.J,_
, ,~
r~.,.......:.,
)
~:-:> {
Employee #: Date: 0/J t / l/ '.
S upe ryis or:~i.;t_~~~~~<~_i{i/':".;;;~"f-;,/'~'i;~~c::-,". -i-~ ;,:,_t.~'_'~'~ ~-. .. -
If Yes, date originai lea~D~eg?'ri;X;1i'~'i'ch~y,i,:j(;. .,
,- -,' :':"~~~':S-~-.;.l~~:""'f;:~:~}"':!"::--"-'~};i-'~:Y;,..,,'_:-:;c,:..,
(Le., non-FMLA leavetmlli(i:i'i)i,'Ji\\ye,perst>i1al) h
, -- '. -:; ::::;;,..;,:-,;,,: :-", -;,';"'--,- -- .:' ., --':' '~.'.-'.,.:--;,.,-.:. ':'-'
~7""", "
~...,:"-.[~ 'v
..:~:,nl"
.Request leave to start:
Projected return itow,9Ial~T~}%t~r';;liH:~'t~W~~~~~~}(
- -i~'_:i,~?t~T~Z~:~~:;~?~:\'~.Xt8t(;~_:~;;;it_~r~!:pf-~~\~?/<!~;:.~-t.'~- <~
'1\.
)(
I hereby request a Family/MedicaILe",ye of Ab~.~nce(FM~A) fromworkfor the purpl)se
My own serious illness, work-r~lated injury/illness. " -
My own serious illness,noil ;;ork-r~l~ied,njul)'/iiiness'::, .. .~.. ._"
~~r~6ff~rc:j~~c~r ~~~~:~t~~ff;~~~~~ir~d~Pti6nii6ster' car~!rli~~;~~~~~~~~l~~~~;('~5';<'."'"
Medical or Informational Facts' ertainin to this leave: ',," " . ',;,,,,,", ",,,.,,,,,, :,.?,." " . ,'.';., ,
t'.'" ~I -, ,-'
" );,.....A...,.....'
If a licabie Date of illness: H;,'::itf~%tt;0,*~1;:\iK;'~tf&(HM"'~:{j:;:-t;'fj;
Ph sician/Health Provider Statement attached ' No"'i~~~~~'~~gali1~,t~'i6'(iji;f~#;ir"n1~;nbe;'
Request leav~ to start: Prcijei:te'a}~furri'k{W~F~w8~fJWj~)i,Y;f;f?~~ "
g~~t~J~fa~Ww~~~~;lsb~~Z~;:~n~:"~~t~:~-t~/111? i . '~.;i~~: :~'~il,:i~~~~.~:bL,;, ~~'5 .~. :;.:0~
"",.> , ,. '_t~.::~:~f,::i:~-r't., :. '-",,>:~,<>?:::i,:;;)\;:~~Ll;;:.::,}:/j{6h~\,:>~i,?)-t'~"~:.;~~'~:_-j;,:.~~~~!r;,>~. :':?if~ti-~j~~'f~~~~::~*eY;~~:if.Ff,~~~' ?~~-:~ ; l' <
Empioyees on ,'n:edical leave, wilt p(qvidean.J'\Ppletoflpapers Inc, .~eWm}tQ.jr1.(9It<i~(ilf,sigpea-,9Ythe.iG,,:-
doctor or perponally provide docum~ntation signed bytheirdoclor tci;.~t:@-:mtMjrJ~~x~;,q:o;i,;~"~t;,;~iii&'EJ?)fi;;
'. ',',<'.." ,',", ".., , ., bY'12:0gnoonto "',;';,'.'.,t(f?t..,;:'i:~c;";,.}?;c?;;;;\~f'!'!".?:';F1::f9?":":'EC:
. ,,'., (DateL,.... ;;,.,.',j.,,',;,. ;...>..":,-;:~,'.,,,,;<<:,...,..' ....x.. .;c.",'; ("... ,(Name)y;,iC,:,':.,.:;',.,:.,:",c;,':{.;,""Z;';
Failure to personally provide documentation 'to eXtend this Leave of Absence or failure to return' to-..vork' on the employee's first'~(
. . scheduled da}r()f work will result in l.oss ofsElniority(employment) 'inaccordancewitlt'....clell.6Eo' "L ',' ""'~rei!r:tie':l:G
- -- '; '-'-:, . -.;. ,:~-~ \', ~::~>, :~.i~;;,,-~ ::~,':::~,>.:,;~-\--;'..,7.o_ :-\:4/;;/f,'_~.:_/;t:~,;,'?j:::,f:{~:,~/;i/-,"(-t> -:;i ,;,).:_- .:i:_~,~-:-~-)~'&';)-~,k,:;.~L';~;:;~~,;g~;& - ,)?~~:~ };t-L
Additional Comments: ",.". ,.", '
'-" < :~-~.~::~:~>:-:';f~':-~_'~.,,_:
- .,-~;*~~~t;i,:~J~~t}0r~~J.~~t11~~~~r~~~~~:{ _:(
Em ploy~e SIgp'a iur~:' '~:", .,..'..,~.. ',-1)/', '/ti:;,~$;ij,~;{;;j~i~:~:'~l~Jl":~~i~;J;~.~~~
Steward's A~knowlE~dgemenf:,.,E;'V7"'f'~" Date"~"'~ ..7f<y".",...,x...,' 1""
'-;-'-~' ,'; .~:;-~;,.;).~':._;;?:;i~~~l~~~~~ijif~i;~~ii~;;~l~i~~:~:;?~;r~~",
. ;:::i:~;':,iFMLA ONLY:~:; .... >:,iJ2",i.+.~~;~Jiil't~W*
Depa~~~~t1~A~ger: ROf.!ti';$~,iX(0C~ '. ';:" ",~D:~~:',;' il I)l{/i,i":i<,:~,-:,~,.,'
~ -, '.'~~;'",~~."~-:">.;:- ,If, -I' ,_~ 'rl \.,"~. ~ ~ ".'" ~l -""(.:>:it:"")~::i-;)- L."';".')',.'';r~';''~_''''';:'''''1~' J- .~'v;~-.
, ~'_".~..' _, ~,-"'" , . ~c..._,-". ~l" ';;",,, ,c -'~"'(J.' ->"',.:''jt'li..!''r;'....'..,........~,-$~'''-''''.il'''I~'"'i'.i~)'...'''~ ~ >,4
H R ,,,-. ", , .. ... .' ., "~_.",,,,h" ,,~'-',", " ' '-
urn,an ,es9lJrces~ ~, d ./ ' . '. . '_ Date;.,/~.<)f~%:~;;;:"; :: ',', .':;'
t":.~".'_IC:::tt:'~~_:::..:-~'_~~~.<-!\~." '" ,~~~. '.- :~:-:-(~_:~.-'~":'.r~~ '::f:1tOl$.~~-~":t.-:'~~Cf-::'~~'{~\\(:.;.:;;~-J." ~':~~;~
Note: :- 7~:' ~ s'./j~~~e./'Of;._bs.f!.n}:e 'l!eg"tlest iSfr...o,t approved until all signature approvals. are obtain'eci by all paRies. crtheir dejegates~{ ';: T:~~:., ~'~ _ r~~.-..,
l~,~" "'~--:<;t'-:.r~.">c-. ~""""""-:.,"_ ~-'"_:' ~'_:-\-"'. "J'; '.'~.-; .~"_;:--'~._"_':),>.F';., __';,.'~'!~' '?-'~;--:;I
White: '~~y. i,;;~i;, '~.Gre~::M~~i;.::, .c: ,.."'~~~~'rY:._.~~~i;~ ': -~ ~. 'Pi~k: ~e;:~ent .... '~ . o~~;d~n;~~:'~~~;~~e~,~ ,: j'
,:::', -_:,,~":~,;i;..:~I{5L~.-,,;;ii~~ ~:t~~ ::'-.~: . . ,~\'!'::,.;~;;~,'r!.: ' '.:,.~ C -.-' '. '--:, :,f~:yj:,;';-~h;:l";j-;:,:..~,' ,-::,;;~-=".i.~?..;;.v,{~_!.-:'f: "-,:,j~;-_;:~::',,..:~.: ;:.~:,.~~:~', ;'~,~;t,
".-".~m)W~'I>1~~II~TfW'I!lIFlnli'!'fl~i~II~~t1i'\!~!!II"'_., ~
"t'"""I"'"'~_><I.'"'",.-~.. ,
"~ ~.
1lt:11l_....
~ ~,
,
'.-',
",.
Request for:
Leave of Absence or Family/lVledical Leave of Absence
, , ,
-",-'
..-'--'
; ,
Name: ,(; '. 'f ",:- ,r." / s.
Department: /.)'.."
Extension: (circle one) NO or YES,
Iher'ehyjequest Leave of Absence:
. . ." - -. .
Facts ertainin -'to:this leave: " ,
"~, ".
.I ~'
, II
Employee #: . Date:.' ..i ,,' , "
Supervisor:~',~k;!.,,,iii"'f"("'_' ,
If Yes, date originalleaVi3;JJeg:a'h;"C{}"\+:;;'>s/i'/0Y ,','
(Le., non-FMLA leave?'ri1ftiGty'I~~~~;p~fs'6n'ai)" <, ','
_,' ',,".:',, _ _:. '.:' -":~~Y~{.;:~~~~'t?:~:."t',\~:,,,~.,._::>?,-:;, "-:;.~,-'''''
Request leave to start:
------
Projected return to0'8rg~[~!~J~~;~1~h>~\1{;~
Y I hereby request a Family/Medical Leave of Absence (FMLAn~~mwo;'k forthe puq)OS~';'
.i'; My own serious illness, work-related injurY/iliness '," , , ' , ." , '.."".'.L " '
My oWr;! se\io~1ilin!"ss-~,no:n}wQ(~-r~late9 inju!Y!(IIr\.es;L" f{;;i:~~l,i>'h~t~~~';:;~;f;.._~..0'/' c" <"
Birth ofa child or placement of a child for adoption/fosterGar~,rExp.~f!l'7~tc.!.HE!",.sJat~:>:..
Caring for a sick child, spouse or parent ' '" ,.,:..,~~1~~1~~;~';f~:~S~i;i'0;;:.;~~;' -.,
. - '. ,. "_,,'_. _"'" ...,.c,.L.<.... ~." .,: I .,. "., ".
Medical or Informational Facts ertainin to this leave:'>'Ti;''i'.,!\?y..,/l':~)f';:'',,; ;-,C
, If a"" 'Iicable Date of illness:'
Ph 'sician/Health'Provider Statem-ent attached ' Yes'
'R.~q~~~n~~xe)9start::~ " ">;'1.iII{"/9 9,'
. Date'oUhenext doctor's appointment;::
, Docv'rli~ntatioiiwas/o/jll be providedO'n: Date:
. ''-: ..::~~:.)~5::r~/ .-, \>~;:: !';:~{f':; "{:, ~'-.~!'.~: j:; ~: ".' ::~_-<;.::.~'~'! '., :7' ~"~"-~:i/;.~~/d~~;(.~:~;:~i:t~:~y.~,~~~~'" ~~ttit{;;~~Ji>'~~Et~~,; ~~ '~ ~-;:: -=,~.:5
Employees 011 medical leave wili provide an Appleton papers Inc.,..) .9,.; J)rKS[ip"sighed bythei("
',' d,~;~~~' ~~,:::;~n~lly.pr;~i.~:~ d~}u~;~tat,~~~~g~~:;~~~~6IrtGtoUrc~t~!!~~~!i~~~~tFt~I~$~~'~\!~~t;
.Fclll~r,~to pers.o9&lIyprovid~~~,5'cumentatibn t.o extend this Leave .of ~bsence Orfail~[eJ(),returnto,~ar~sntb~,emJl!()Y~El:~.~,~r3.,
scBedllled day ~work Will result In loss of sentonty (employment) In accordance wit '. e.6,6E ofthe, Labor'lS,greemen!;\;.;',,::
- <~{~~;r~ .;,~:: J,"~..>:7&:!,:t: <{-;:'" -:~~ -~-~~;WYf: -? ,,:,~.~-:!:.:,.:'~~,~>~_:,;. --':.. " ~ ,": ;:-_ ~," <':., ;~,,~..' .':'=. ~.:' c~ '. ~1.i ~~lt~~~~*J:*~~vl~i~~~~~~~~ii%.~,/~Y,~~{
<;'~~WKtf$~1~~~~*l':;r::, ~-
1~Yt~;.~gaJ,,~~mM~p~~~~;~ '.'
Employee Sl€lnature;~.; ,""".f
,~c~f.~~rd's';~t~'dWI~~h~en-t:'.{.,t-..,.,
:~~, '~." Il--,~-:'-~-
^ II ,>,'-
:\} ! c.'
/- '~:_ .~.'c,-'
, '
",
;:Jm1$-'Il!l\W'*'1i\'IV1l][1I]f1i!l1l~~ffiIlIIf1l'--III~:I'lm~4ITI"1~I~~"F"'!
"~"'~~T
r'-'-'~'"?l~"'
. I "'"~~"
~ 1!I~,","""_~''"'I","r~~I~",n,Ol'If'i'l''''!''~I''''I'~!lmrl1l",~
;j'.l>.
," ~-/
. .
- "J'~ ....
, .- ,-/
"/
~{f
Request for: , ,;:;<
Leave of Absence or Family/Medical Leave of Abs'ence. .
Name: I)' a'L~Z~.~ 'EmPlove:e#:,J?~?J6ate: y/9/97"
"Department':- Supervisor,:'j{c:ifii'~(';~D;",:'f,~~;:.;,;j). ~',.;:;::'
Extension: (circle cine) NO or YES If Yes, date originalleqy:ei!'\fig-an'Pr;"">~"'4 "':-:,;)/5 ,y<'
. ", .' ";"~;;'-"_'2';;"L~'~'~'\::'",'_ -', r_;::, ,;'.~.: .'--...,.,,>', ,'': "
Lhereby request Leave of Absence: (i.e., non-FMLA leave,rlj:UrWtYl.ecl\/e, 'personallR'p";
...... " -.' - - - -- "',.".,,.~-~.,,~,<,;. -.-,:. -- -."." - ,-..... --,:,--::-, ,----"-:~
Facts eliainin tOithis leave: '" ,. " , " ..,', ,...,'... '., '. .,' ','
-".;....,.
--,<'';,':''':
/
Request leave to start:
Projected return to vJ~f~i~{~~;~15~~?:;?,r~~:;r{K,;"S)X:;~> .:.,..
':: ~!~fi~~~~J,~~0i:~l~;'I.i~~/tt$f;~~~-~k;f:;~~~t;~{i:2,: ?~', :'
/'C
~- '"'-:-'_',-
T',..:;~c.,>f .-~'. ;,:..\ '., ~::~~,;!~;,~,~€~
Dep~1i~~;:;L~,i<~.:~~~~:;:()~Lt~~t~:i~~~~\,f~!
: ."q--"",,,"~'--' """"'9"f\II'W'JII"~~ !~II!'111101'fil19"-'!1!P'j'W1I"1i~~111'\'f<'~~I~ "r-1t'l"II" ~VJmllI!nJlQlJll [ .
~ ,"H~'
"""",/IIIIIIIt1'II'_!
. "" ~ n I
r-,,!""'!llI~""'I~~--;::
~~~~;-~~--"
p.
1" " ,- '-)J~ '
C ,'_ .:~/ .- -'--, :,..
.'" ~:~~.-.:c ,:_._'.~,",' ,,_
'.j""--
,
Name: rJG {".... 1 (.'a...fJ'V- "":
"
Department: ", \ ')..0',
Extension: (circle one) NO or YES
I hereby request Leave of Absence:'
Facts ertainin to this leave:
Request for: :
Leave of Absence orFamHy/Medical Leave of Absence
'i/76i1f
Emplo~ee'#;.? v) 1 'Date:
Supervisor:
If Yes, date originai leave began: k':
-. , ,~ - .' c ,.' 1
(Le., non-FMLA leave, military leave, p~rsoi1al)
. . ft,
'\
. ".:I<Y~
.' J ~t. T til,
'.r:,,,:;'_
'j
. )-.{
1
" "
. :-J.
Req u~st le~ve to start:
. - -- . -- , ~,). -. '. ,', .~-" .--" .. -
Projected return tO,work :date: '
- - ~.
. ",,-,:
);
)(
,'"
Supervisor:.,::'"
'::',-:: ;....:. ':';-'~-!;;"""~;(,~{"-.\-,~. - .,'<::,.' "
,
Human Resources:'
'.; . Goldenrod:Empl\lye1W&"",
.'..-~".;. ': '0 -..r.' .:,-i' ,'. :'""-"' ,.-,
'......,. _.-
"
. ':.'~_ 'c-., .'_ ~'..'.'-'...
,,'~.wr""Iffl!~l!!g~iJlll!l'fI-'I'?I!l~I'II'l~rll~HI"'l~fl~~.f""" ""f"'I"""""'IIIW"'lll'l' I '~'I "''''''"'~'"~\>'~_,~"" "~~_""''''''''''''.'_''' ,~~ ~""~ --...,_IJilIll_lmil!llllllllil' ~~- ~,- ..~
. -- 'L-' ~
..
Request for:
Leave of Absence' or Family/Medical Leave of Absence
Name: 7)c"'A,v T';:- ,~~
Department: ,[:C.;j (, '- f" { .''';'!'' J,'"
Extension: (circle one) NO or,YES',
I hereby request Leave of Absence:
Facts ertainin to this leave:
Request leave to start:
'-4 -,----.. ;f' I
Employee #:'>;;'s" Date: / (> ,;,."Lv';r,
Supervisor:, ,..'.
If Yes, date original ieave began:,'/,,'/;,;.'-f 9',
(i.e., non-FMLA leave,rnilitaiyleave, p~rsol1al) ,
. . . - ~.:~.~
I(~.C--; C
. '
I hereby request a Family/MedicaLl.eave of Absence (FMLA) fromworl5forth~pJrp~s~:"-
\/" Myown serious illness, \.~;k~~elatedinjUjy/ilin:ss '. ,," . ,,?;(~~._;~.:~t;:C}t-r':;,:~:;,!:!,j:;'0:-.
My own seriousillness,noii-wO:rF~rerafed injury/illness -" " ,. i:e .
Birth of a child or placement of a child for al:!ciption/fosterca~
Caring for a sick child,spouse or parent " ,
Medical or Informational Factsertainin to this ieave: ,"
If a licable " Date of illness: .
Ph sician/Health Provider Statement attached
..;, ,... .',.. -, . . .
Request leave to start:, ' '
Date of the next doctor's appointment:c.::;f.'X, J,' :; 1"7".,
Documentation was/will be prov'ideclon:;,: Date: .,C,
- : " - -.. ,~- ,-:~' -. ,:,. ,<" ~~ t-:' ~',:: ,:\.~.';~'~-.'\<;-< .i~~:S;{;:~~}~~}!?>~~~.'..:. :,'.~~: dr~'.\h'~ :.< ,..' -." ,: '.: ~~j'r~<:~3:-;0:,~;1't~~:~~~&:~J;-~~~i ~:~-;~~~j',;r:~:'~~:;~
Employees on medical leave will provide an Appleton papers Inc, FietuiiOR tyorl(S/ijfSi9Qe,o.by 'their",.:
doctor,~~:~~~~"provi~,~.~~~u;;~~_t~t1~f~?g~J;~~~lrdo~tor}~:~~:~~~~I~~~~;~~f~~~~1'~c;
Failure to personally provide documentation to ~xtend this Leave of Absenc~ or failur~ tor~furn td ,workori the:'~h1pI6ye~'s' fjr.st;;,~:
scheduled day of work will, result in loss of seriiority(empldyment) inaccordariC$wii~\AritCie:ii:6EQf tf1erab'ili;Ji:g1-eeriient:t~0~q;~~
'A'd: 'd:<,'tl' "o',:n" a:' 'I',' 'C''; ':'~,o' .'m'~' ;m'---'-'le' -on; ':ts~~'.>'-"" ~ >: .: .~: .J; i:_';~,:'-'?~: :::~~ ,.,-,;.~,~. ,;;;: ,~;:;;, y-:;-~ ":'< :~:. .-~> .~, :,,~':;.T~.}~':s~~M;f}B~~b~~$;~~~\~" , . '<ik~~~~~~;~~4~~:~~;~:::;"}:
. - '.: .-:,.. ; -, ~ ~'~'--~ -:-"! .-,-(, ;.,.:-'.:::'~' :';:;'";'=;",'::''''f'~~~~~;:'~'';''~~~,:;~f./{i;j;~f;~. (.-4~~~~}~;:\~$.f-~1';;:r;-~:t{.:,;~~,:::",: ,~~
,.- ~-'. ',:"~' ;;~Jt~~ij i:1~~~f:@~~~1;~:;~'{m~~fi,@~~~1~~;~t;{~~~: ~~
" .'.,.\:::..
Department Manager:
- . '.''-, - -'.: .'
Employe~ Signature:
Steward'5'Acknowl~dgemEH1t: ,
Approved by (FMLAONL V):
"~/ "
, ~ _J--..
~~~'- -:'i tAM'-:':-
-', ..
',\. ,..,]
" .'~':;';'~
,-" ,',"
"''"-,..'-'" ,."
SuperVisor:' '
,.' './-:--(~2 ' " '
'."',,~... -_.~..:.....
, ) '/'
Note.: -
White: Payroll, ,,'Green:
Caiiary:
-.~ "
-'.'-- -
~ '1",~,,~~Wf!~'0\1f'1~11$II""~5'II':W," . ~~ ~~,...." ~
I'
-n
_:1_1ll11!lf~m~Ili'RIIlI~~IIII!i/llfI~PmIl""l!Il1llM1ll1lmlll_IBllII!IlIIMlIiIIIl'lRJel'UI!IAI!fi!!lIIlll!!'iHI'llII!"~~FT<i~-
~
Name:':.p(-O fl.-I ;-;,. PI-I" Ie:-.
Department: /.:~l:,,: "
Extension: (circle one) NO or(l'ES )
I hereby request Leave of Absence:
Facts ertainin to this leave:
, Request for:
Leave of Absence or Family/Medical Leave of Absence
, - J 9(/ _,l,~;/' / (/ (/
' Employee #>/0'.2 Date: c , / I
Supervisor: :,__;;<+~"; ..-:S/)~i'~\-::::,~):~~:{;:/-~:i\;-'j"l~::':":J(: ,~_: '
If Yes, date original leave begari:";!ccS,' J.",
(i.e., non.FMLA 'eaVe,rl1i1it~:ry'eav~,;p~'rs()ha')
Request leave to start:
, . ":'.,-,
Projected return to Vyork
I hereby request a Family/Medical Leave of Absence (FMLA)' frO'ir(wbrk iorthepiirpos~': '
My own serious iliness, work-rel~tedinjury/iIl1iess', ".;,(""",:;~,;"'i:'~,5;:" '!,,'j"
Iyly" own,serious.. illness,non, worK-related injqrylil1n~~s~"", ,'.,;,',(;, ;;i~'2~-i;~:iii','';;;'!;'i:.'i;,j:.;(''';,,(;;<;,\f
Birth of a child orplacement of a child for adoption/foster care,'ExPE!'gt~dduejla~g:\;;'c;;Y,:'
Medi~:lr:rgl~~~~~~~~oC~:I~~:~~us:~~i~~e~: this leave:'....' ' .;,:;~;q~~~~i~i'i,~;lt~;~tlf~fB~~~:&2,J.;.G.~;{,r.,
<
'".'
~'>"
If a Iicable Date of illness:
Ph sician/Health Provider Statement attached Yes, or ,,',,' ,i~dl~dEiti\~eid;i~d~;:~ioriln;HiW"rf,~nii,~r,!,~
,Requestlea'le to start: Project(3d,iefYrrnQWR~k~~~t~i,;iJ;g'?7i;f.f/';i",;
.g~~~~~f~~~~~~'lsF~~~~Se~~~:~;'",Da~e: .,'...~,"i~;.~'E~-,L~l~~~~il~i~~;~:~~~~~~~t;~"
Employees on medical leave wiii provide an Appleton papers Inc:' Re([im<to'Wd[I<VSlip,sig'hedbHhei(;~'
Failure to personally provide 'doc~mentatiQnto e~end this Leave of f\bsence orfi'ilui~to,K~.tW(\ \0 Wflf~:p,I.il!1~,effi8IB~~.~~~~~k2
scheduled day of work will result.ln loss ofsenlonty (employment) In accordance v;,lthArtlcle:(j.(jE,oUhe,I;J3Q.oc;Ag(eemen,bl';'!(ii'.':
A~:dt1:i;~~i~c~'~me~~i:;:'i"'<'<c';""'::";' ";>f,i,;~;;:",..'::;,,";.;'L;,:~~};~;:~=:~~~tlOfql1f;rt~*"'f'ji<;t',:t7f~~
, " :'''' - . ' _" --,~ -- , _. . _' i _'
Approv'edby (FMLA ONLY):
-~""',-~\....._,---,--:'
:i',"'~ \:'
-, ',.-.
Employee Signature: " '
, -"'.:--' --. -- -c.
.' S t~war~'SAck~:6wl~dg~~e;nt:,)
,,' -x/k~
:; 'I j, ,<~.
:'~.~:-~\:~;,
Supervjsor: .
'-.-' -, ,-
Department Manager: ,
". '-".- ,,:,
.- "- -; ~ - <
'-,,;).'
',. ,-;;-,C ;:,;"~,'::"~,:,?
Note: > _ Tf.I.l~ ,Le.C!ve_ ?' Absence Request is.,~of;fpprove'd uri~i(all sig'n~itute appro'vals are o-6:t?iilecl by:iJ1J'pa:;fi.B!; Ci(tii~j;:'i:jet~gate~;'~~ni.y.~;:~:.::-~~~::,'!';~/i'-
,~,White: payro1i: .'," Cahary:HR'File' 'Goldenrod:Eiiiployee;cf':'<"r
<_~,::~"~:~"':,,~,',',,::',"',,;,~,,_,,.',, .r,~~,",~""". .. ., -- - . ' , ;'- '-", :- , . I ' < ""r.' ... 'I"' , '.~ '" "~ .,.,,:,.,- .-....,".,',.:".'_',',',',.~,",'_,:,,','~,.._,.~,','," ','.-~~",',.',',;,.,>,..'~,.,,',.,:.-~.,:_,i_;:.,~,';,.,','~._,,:,:;,.\,','~,',:,
',<",';'~_~'; ';.'" ~ '.-",~',:.-~.,;:-~~:(~";;~'flt.~!;::,~-~,__~~f.:~i~.;j;:~;;:;~;,;:"!,:, _,,- ~',:~"":. -c.. ~ - ''';'
;:"~;tJ,'1~''!o;1I1Flf,,~",.'''"''''''''''''', ..,,~
1I~1""OI'!"l~ _ ~~_,., ~
~-'r -...\"'
~-~
_..~= ~!""~~~p~.,.~I\Il__I!IlI_I'lI__II~!III___'r"""~="~
..
R(j-qlJf.' s;t :~(":';
Leave of Absence or Famihrmi'i(\d[c~ille<l\II' O'f Absence
~ J' /()/Z~
--LJ "," ". - -,If; i -~_;. ~, .' , {,t~ .
fJall1e~___ ~"L~d<'~"::.2-=.~~~__"._._ '.., __1:.l)!PI'2:,:gc,~'~~.'-,:::.{:I~<l.!e:___nL.:_ __t.1' __
_~~:.~.:l.lil~lent: ____._____1 G'" ...._=', ._____.____~ll~e(';'::r:,,~'.J..:.---J~,-"'jl._____ptlr2L.tl(,'~------
Extension: ._..J<:l:cle on~_NO or ~~1lf_~~~. d?~':",O..r:Ij!~f2:3J__~e~Cl.\~~.!J~~!! .
E~)~' ~:~:~~n;~J;~~: ~:::: of .4bSell~_~~_~i~t~~_lon.::~~~^_~(la'~.::,~:'.~I:<~~_1'~~~:~~_~~:~~al)
t---.---.------------------- ------------ __..u_______ ---------.---- -. -------------.-------
-R:~qlles.ti~-ave t;;-start:' J!'rOj::,c!,;d' ret~~~~'~~~~i:-';;, tro..----------
-~--_._._-~.._---_..-._----_._-_.__._-------
----~--
I hereby requost a Family/Medical Leave of AbsNIGe (FML.A) fro'f) work for the purpose
My own serious illness, work-related injurylillness
_' My own serious illness, non work-related injur)'/iI1.1ess
Birth of a child or placement of a child for adoption/foster care Expectod due date:
--,
J Caring for a sick child, spouse or parent
f-d,edi.cal olJnforrnational Facts pertaininQ jQ thi~~a\(E;..___~___._~___._,..._ '_____.______
IF-apolicabje) Date of illness: ____..______.________________.____
P_l1.vsiciqn/Heijlth Provider Statement attached Yes or No _____..il!lGl~f~;;Jl~'2;lto caw for ill family member)
Request leave to start: . ~i:cted retu~'1 to work date/r.<.J~ ~f/
Date of the next~tor's appointment: 1c:J--b-9 f 111 / I .
DCCi.Hnentatjon~will be provided on: Date: ~/*~_.__ To: g'---4~/;~
Employees on medical leave will provide an Appleton papers Inc. f~'elum to Work Slip signed by the
doctor or personally provide documentation signed by their doctor to extend their leave on
by 12:00 noon to
(Date) (Name)
Failure to personally provide documentation to extend this Leave of Absence or failure Ie fI,lure, to wort< on the employ"e's fir,
scheduled day of work will result in loss of seniority (employment) in accordance wi,h J\rk.le 66E of the Labor Agreement.
I Additional Comments:
Employee Signature:
'---~-~._-_.-----_._---_.-....
>( (L---:i~-:.~==-='~=~ Da~e: /0-"1-7: 1-
_______n_____ ____"'.....,._.._______ Ca'!e-:_______
S'.eward's Acknowledgement:
-........-.---.---.-
-..---....-...-..-..._.~.____..'.....__.__'.........n.......-'"""'....'_.._.______,___._
Approved by (fMLA ONLY):
Supervisor:
Dale:
DepaltmlJot Manager:
Human Hesources:
Date:
Date:
Note: Thhi Laave of Absence Request is not approved until all signature approvals .are otAair",..d bV aN pattiE'S ai' their delegares,
~~~te: Pa'lroll
I Green: Medical ____[C;~:;;;;;: HR ~..'!.'~=---=-TF;;:k .D;;'3rl';enl ~=~...()~enror: EmploVee
..Ii> ~_~," ,~,~,~
~[!""I'"'
~,=~ .~~~-" ,.--
,
Ji
A~':' ~
,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
Bureau of Workers' Compensation
- - - x
In the Matter of:
Dean Teeter,
Claimant
vs.
Claim No. 2051428
Penalty/Reinstate
Appleton Papers, Incorporated,
Defendant
_ _ _ _ _ _ - - - - - - - - x
Pages 1 through 36 Hearing Room A
Harrisburg Judges Office
East Gate Center
1010 North Seventh Street
Harrisburg, Pennsylvania
Thursday, February 22, 2001
Met, pursuant to notice, at 2:30 p,m.
BEFORE:
KARL H. PECKMANN, Judge
APPEARANCES:
JASON P. KUTULAKIS, Esquire
8 South Hanover Street
Carlisle, pennsylvania 17013
(For the Claimant)
ROBERT J. GODUTO, Esquire
Fifth Floor
305 North Front Street
p, O. Box 1003
Harrisburg, Pennsylvania 17108-1003
(For the Defendant)
Commonwealth Reporting Company, Inc.
700 Lisburn Road
Camp Hill. Pennsylvania 17011
(717) 761.7150
1.800.334.1063
-,.
" ,
~I' ~" - ,
.-,
. ,
.
I
i
I
I
i
.
~
~'-"!ffilr.i\"~~ ,_,~
~_, :--:-:-11'
17
the decision not to come to work.
2
BY MR, KUTULAKIS:
3
Under the union regulations, is an accepted leave of
Q
4 absence defined?
5
A
Yes, it is.
6
Q Okay. Was he on an accepted leave of absence under
7
those regulations?
A Based on -- based on the union contract, yes.
8
9
MR. KUTULAKIS: Nothing further, Your Honor.
10
JUDGE PECKMANN: Anything else?
11
MR. GODUTO: Yes,
,
12
CROSS-EXAMINATION
13
BY MR. GODUTO:
14
Q Mr. Honafius, in terms of the documentation that was
15
submitted by Mr. Teeter for a requested leave, when were
16
the last time those documents were completely filled out to
17
continue the leave?
18
A
The leave of absence form was filled out completely
19 on July the 26th, and that leave was signed off by his
20 supervisor, department manager, and human resources.
21
Q
What's required internally -- first of all, what's
22 required to have an approved leave?
23
A
Ah, to get the approved leave of absence, the
24
employee must present medical documentation that they have
a disability or are unable to perform their job, and they
25
" I
,"""" 'I
- ~ "I
-, "",...-
}
.
EEOC Form 161-B (10/96)
, ,
.
U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
NonCE OF RIGHT TO SUE (ISSUED ON REQUEST)
To:Dean A. Teeter
1605 Walnut Street
Camp Hill, PA 17011-3971
From: Equal Employment Opportunity Commission
Philadelphia District Office
The Bourse
21 S. Fifth Streol, Suite 400
Philadelphia, PA 19106-2515
On behalf of person(s) aggrieved whose identity is
CONFIDENTIAL (29 CFR! /60/,7(0))
170A!0385
EEOC
Representative
Stanford Lamb, Investigator
Telephone No.
Charge No.
215-440-2617
(See also the additional information attached to this fom
NOTICE TO TIJE PERSON AGGRIEVED:
Title VII of the Civil Rights Act of 1964 and/or the Americans with Disabilities Act (ADA): This is your Notice of Right to Sue, issued under Ti
VI! and/or the ADA based on the above-numbered charge. [t has been issued at your request. Your lawsuit under Title VII or the ADA mnst be file
in Cederal or state court WITHIN 90 DAYS of your receipt ofthis Notice. Otherwise, your right to sue based on this charge will be lost. (The
tinte limit for filing suit based on a state claim may be different.)
X More than 180 days have passed since the filing of this charge.
Less than 18.0 days have passed since the filing of this charge, but I have determined that it is unlikely that the EEOC will be ab
to comp[eieits administrative processing within 180 days from the filing of the charge.
". . ,- .,
X] The EEOC is ierrnmaiing its processing of this charge.
,"::-..(-,'" _!
] The BEOG will' contUme to process this charge.
'~i"
Age Discrimination in Employment Act (ADEA): You may sue under the ADEA at any time from 60 days after the charge was filed until 90 days
after you receive notice that we have completed action on the charge. In this regard, the paragraph marked below applies to your case:
The EEOC is closing your case, Therefore, your lawsuit under the ADEA mnst be filed in federal or state court WITHIN 90
DAYS of your receipt ofthis Notice. Otherwise, your right to sue based on the above-numbered charge will be lost.
The EEOC is continuing its handling of your ADEA case. However, if60 days have passed since the filing of your charge, you
may file suit in federal or state court under the ADEA at this time.
Equal Pay Act (EP A): You already have the rightto sue under the EPA (filing an EEOe charge is not required.) EPA suits must be brought in
federal or state court within 2 years (3 years for willful violations) of the alleged EP A underpayment. This means that backpay dne for any
violations that occurred more than 2 vears (3 vears) beCore you file suit may not be collectible.
.fyou file suit based on this charge, please send a copy of your court complaint to this office.
On behalf of the ~n
-~ ~-!~~~
\-n-tJ\
~nclDsure(s)
Information Sheet
c: Appleton Papers, Inc,
Iason P. Kutulakis, Esquire (for Charging Party)
Marie M. Tomasso, District Director
(Date Mailed)
j~!$]~ ~- ..~~ ~
~ "
.
.
CERTIFICATE OF SERVICE
I, Jennifer L. Murphy, Esquire, one of the attorneys for Defendant Appleton Papers Inc.,
hereby certify that I have served the foregoing document upon Counsel of record this date by
depositing a true and correct copy of the same in the United States mail, first-class postage
prepaid, addressed as follows:
Jason P. Kutulakis, Esquire
ABOM & KUTULAKIS
8 South Hanover Street, Suite 204
Carlisle, PA 17013
DUANE, MORRIS & HECKSCHER LLP
Date: May 3. 2001
'~",l;i-,.][ """, ~ "_
, .
, <',.-'.I'-!
, . ,
"
.
CERTIFICATE OF SERVICE
I, Jennifer L. Murphy, Esquire, one of the attorneys for Defendant Appleton Papers Inc.,
hereby certify that I have served the foregoing document upon Counsel of record this date by
depositing a true and correct copy of the same in the United States mail, first-class postage
prepaid, addressed as follows:
Jason P. Kutulakis, Esquire
ABOM & KUTULAKIS
8 South Hanover Street, Suite 204
Carlisle, PA 17013
DUANE, MORRIS & HECKSCHER LLP
Date: May 3, 2001
',~.~"";""""'~
~~A_, _ ^.
'1--:' ,-
- ~
Curtis R, Long
Prothonotary
,e
Renee K. Simpson
Deputy Prothonotary
John E. Slike
Solici tor
<l&fficc of tbc llrotbonotarp
QCumberlanl:l QCountp
Court of Common Pleas
Cumberland County, Pennsylvania
Docket No. 0 /-:<2/1 cl~11
THE UNITED STATES DISTRICT COURT FOR THE
MIDDLE DISTRICT OF PENNSYLVANIA
Please acknowledge receipt of this case by signing and dating this
document. Please send this back to:
PROTHONOTARY OFFICE .r
CUMBERLAND COUNTY COURTHOUSE
ONE COURTHOUSE SQUARE
CARLISLE, P A 17013
Attn: Becky
Record received:
Date:
(signature & title)
jY)o)d
'), tj-O/
One Courthouse Square' Carlisle, Pennsylvania 17013 . (717) 240-6195 . Fax (717) 240-6573
0~!"" ~~,__".' ~
~ ,F
.-
, .
I~