FAMILY AND MEDICAL LEAVE FORM

An eligible employee may take up to twelve weeks of Family and Medical Leave during each consecutive 12-month period for which eligibility criteria have been met. The initial 12-month period is measured forward from the date the employee first takes FMLA leave. The next 12-month period begins the first time FMLA leave is taken after completion of any previous 12-month period. Family and Medical Leave shall be granted for the birth or placement of a child for adoption or foster care; for the care of an immediate family member (child, spouse, or parent) with a serious health condition; or when an employee is unable to perform the functions of his or her position due to a serious health condition. For leave taken for the birth or placement of a child for adoption or foster care, entitlement expires at the end of the twelve-month period following the date of the birth or adoption placement.

                        (1) have worked for the University of Illinois for at least twelve months;
                 and
                        (2) have worked at least 1250 hours of service during the previous twelve months.

Serious health condition means an illness, injury, impairment, or physical or mental condition that involves:

· any period of incapacity or treatment connected with inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical facility;

· any period of incapacity requiring absence of more than three calendar days from work, school, or other regular daily activities that also involves continuing treatment (or under the supervision of) a health care provider;

· any continuing treatment by (or under the supervision of) a health care provider for a chronic or long-term health condition that is incurable or so serious that, if not treated, would likely result in a period of incapacity of more than three calendar days; or

APPLICATION PROCEDURES Employees should complete the TO BE COMPLETED BY EMPLOYEE portion of the FMLA Leave Form and submit it to their supervisor. The supervisor or department designee completes the TO BE COMPLETED BY DEPARTMENT portion and returns to the employee. A copy should be retained in the department separate from the employee’s personnel file. DO NOT SEND A COPY TO THE HUMAN RESOURCES OFFICE.

Note: UIUC Academic Professionals (AP) and Faculty must receive approval for unpaid FMLA leaves. Forms should be submitted to the Academic Human Resources office.

Certification issued by the employee's or the family member's health care provider may be required to support a request for Family and Medical Leave due to a serious health condition (see attached Medical Certification form). Requests for paid leaves shall be in accordance with the University's sick leave/vacation policies. Departments may require employees to provide the opinion of a second health care provider designated or approved by the University, but not employed by the University. The opinion of a third provider may be required when there are differing opinions. The opinion of the third provider shall be considered final and shall be binding on the University and employee. Any expenses associated with obtaining second and third opinions shall be the responsibility of the employing department.

The department may require an employee to obtain a statement from a health care provider that he/she is able to resume work. Employees are expected to contact employing departments at least thirty calendar days in advance of the anticipated date of return. A staff employee who has been absent for Family and Medical Leave shall be restored to the position of employment held by the employee when the leave commenced; or an equivalent position with equivalent employment benefits, pay, and other terms and conditions of employment.

Birth or Placement of a Child for Adoption or Foster Care: Employees have the option to take FMLA leave with or without pay. An employee may request to apply accrued vacation and/or sick leave during the twelve-week period in accordance with Policy and Rules for Civil Service Staff or with campus Academic policies. Any portion of the twelve-week period for which accrued leave is not applied shall be without pay.

Serious Health Condition, Family Member or Employee: Employees have the option to take the leave with or without pay. For care of a spouse, child, or parent with a serious health condition or because of an employee’s own serious health condition, the leave is provided under the University Sick Leave policy (Policy 10, Sick Leave) and the campus Academic sick leave policies. If an employee’s sick leave is exhausted, the employee may elect to use accrued vacation and personal leave to continue in pay status during the FMLA period. Sick leave, vacation, and personal leave used for this purpose will be counted towards the 12-week entitlement.

In addition, employees with a serious health condition, who exhaust their accrued sick leave balances, may be eligible to receive disability benefits through SURS. Employees may request an APPLICATION FOR DISABILITY BENEFITS from the campus HR office. Any portion of the 12-week period for which accrued vacation, sick leave, or disability benefits are not applied shall be without pay.

Coverage of group health and dental insurance shall be continued by the University at the same level that coverage would have been provided if the employee had remained in continuous employment. Employees are responsible for paying the employee-paid portion of any insurance premiums presently paid by payroll deduction. If required payments are not made by the employee during the leave period, insurance coverage may be DISCONTINUED, and the employee will be offered continuation of benefits through COBRA. Employees are encouraged to contact the Benefits Center to arrange for billing within thirty days following the last day of paid employment.

Employees pay the entire premium plus a 2% administrative fee for COBRA coverage. Central Management Services (CMS) mails monthly billing statements to the employee's home address on or about the tenth of each month. Bills for the current month are due by the twenty-fifth of that month and are paid to CMS. Individuals electing COBRA coverage have 45 days from the date coverage is elected to pay currently due premiums. Failure to submit payment by the due date terminates COBRA rights.

The University may recover any premiums paid for maintaining coverage for the employee if the employee fails to return from Family and Medical Leave for a reason other than continuation, recurrence, onset of a serious health condition (employee or family), or other circumstances beyond the control of the employee. Certification of such conditions may be required by the University.

To determine the effect of Family and Medical Leave on the accumulation of service time for retirement and to assure continuation of contributions, the employee should contact SURS at 1-800-ASK-SURS.

Employees should discuss questions or disagreements about leave under the Family and Medical Leave Act with their immediate supervisors. If concerns are not resolved at the supervisory level, the unit head should review the issues. If the unit head is unable to resolve the issue, the dean or director should be consulted. Should questions remain, the campus human resources office will provide assistance to both the employee and the unit.

Interpretation of specific requirements of the Family and Medical Leave Act policy is subject to provisions contained in the full text of the Act. Questions regarding the provisions of the FMLA and the Department of Labor Regulations for its implementation should be directed to the campus human resources office.

FAMILY AND MEDICAL LEAVE FORM

Effective August 5, 1993, the University of Illinois implemented the Family and Medical Leave Policy in compliance with the federal Family and Medical Leave Act (FMLA) of 1993. Such leaves shall be granted to eligible employees for the birth or adoption of a child; for the care of a child, spouse, or parent who has a serious health condition; or when an employee is unable to perform the function of his or her position due to a serious health condition. FMLA leaves are granted by the department/unit. Eligible employees are entitled to up to twelve workweeks of unpaid family and medical leave during each consecutive twelve-month period for which eligibility criteria have been met. Employees may substitute accrued sick leave and vacation & personal leave for unpaid FMLA. The initial 12-month period is measured forward from the date the employee first takes FMLA leave. The next 12-month period begins the first time FMLA leave is taken after completion of any previous 12-month period. Requests for Family and Medical Leave should be made at least thirty days in advance of the leave, if possible.

TO BE COMPLETED BY EMPLOYEE

Employee Name: _____________________________________ UIN: ____________________

Dept./Unit: __________________________________________ Office Phone: ______________

Title: __________________________________________________________________________

REASON FOR LEAVE

______ Serious illness of employee*

______ Serious illness of spouse, child or parent*

Name of individual: _____________________ Relationship: _____________________

______ Birth of a child

______ Placement of a child with employee for adoption or foster care (attach legal confirmation)

*Medical Certification may be required

REQUEST TO USE BENEFITS

IF NO AMOUNTS ARE ENTERED, THE LEAVE WILL BE UNPAID (MARK ALL THAT APPLY)

______ Apply all vacation leave OR ______ hours/days of vacation to this leave

______ Apply all sick leave OR ______ hours/days of sick leave to this leave

______ Apply parental leave ______ Apply as unpaid leave

Anticipated date of delivery, adoption or placement

EXPECTED DURATION

LEAVE WILL BE TAKEN AS (check one):

______ a block of time from _______________ to _______________

(month/day/year) (month/day/year)

______ intermittently (e.g., separate blocks of time) (please describe on separate sheet)

______ temporarily reduced work schedule (please describe on separate sheet)

I have read the “Employee Rights and Obligations Under FMLA” handout attached and understand all my rights and obligations under this policy. I also understand that any leave taken as designated FMLA leave (paid and/or unpaid) counts toward my twelve-week FMLA leave entitlement.

_____________________________________________ _____________

Employee Signature Date

TO BE COMPLETED BY DEPARTMENT {SEE EMPLOYEE RIGHTS AND RESPONSIBILITIES}

1. Has the employee worked for the employer for at least 12 months? Yes No

(If no, the employee is not eligible for FMLA.)

2. Has the employee worked 1250 hours (64% appointment/37.5 hour workweek; Yes No

60% appointment/40 hour workweek) during the previous 12 months? (If no, the

employee is not eligible for FMLA.)

3a. Is the reason for the leave because of the employee’s serious health condition? Yes No

3b. Is the reason for the leave because of the employee’s parent, child, or spouse’s

serious health condition? Yes No

3c. Is the reason for the leave because of the birth, adoption, or placement

of foster care of a child by the employee? Yes No

4. Does the employee’s medical certification (which is required for employee’s own

or family member’s serious health condition) support the request for leave? Yes No

5. The employee has _______ number of weeks/hours of FMLA leave entitlement

remaining at the time of this leave request.

Based on the answers above, is the employee eligible for FMLA? Yes No

If no, state reason.

_______________________________________________________________________________

The department acknowledges that benefits will be applied as shown on the first page of this form:

______ vacation leave hrs ______ sick leave hrs ______ parental leave hrs ______ unpaid hrs

______ vacation leave days ______ sick leave days ______ parental leave days______ unpaid days

Please sign below to indicate your review of this FMLA request.

_____________________________________________ ___________________________

Authorized Departmental/Unit Signature Date

If the department believes that the employee is not eligible for FMLA leave, please consult your campus Human Resources office before denying the leave. You may also contact HR if you have additional questions.

The department is responsible for tracking FMLA usage on an FMLA Usage Report available at

https://nessie.uihr.uillinois.edu/pdf/leave/fmla_usage.pdf