FMLA
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[INSERT COLLEGE OR UNIVERSITY LETTERHEAD]

Employer Response to Employee Request for Family and Medical Leave

Family and Medical Leave Act 1993

Date: __________________

To: ____________________ (Employee's name)

From: __________________ (Name of appropriate employer representative)

Subject: Designation of Family and Medical Leave

On ______________________, you notified us/we were notified of your need to take family/medical leave due to (please check one of the following):

The birth of your child, or the placement of a child with you for adoption or foster care; or

A serious health condition that makes you unable to perform the essential functions of your job; or

A serious health condition affecting your spouse, parent, or child (please circle one) for which you are needed to provide care.

You notified us/we were notified that (please check one of the following):

You need this leave beginning on ____________________ and that you expect leave to continue until on or about ____________________ or unknown at this time.

You need this leave intermittently from ____________ to ____________.

NOTE: ____________________________________________

Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid leave in a 12 month period for the reasons listed above. Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work, and you must be reinstated to the same or equivalent job with the same pay, benefits, and terms and conditions of employment on your return from leave. If you do not return to work following FMLA leave for a reason other than (1) the continuation, recurrence, or onset of serious health condition which would entitle you to FMLA leave; or (2) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA leave.

This is to inform you that:

You are (eligible) (not eligible) for leave under the FMLA.
The requested leave (will) (will provisionally) (will not) be counted against your FMLA leave entitlement.
_______ You have furnished us with a medical certification or a letter from your doctor.

_______ You (will) (will not) be required to furnish medical certification of a serious health condition. If required, you must furnish certification by ______________________ (must be at least 15 days after employee is notified of this requirement) or we may delay the commencement of your leave until the certification is submitted.

You may elect to substitute accrued paid leave for unpaid FMLA leave. We (will)(will not) require that you substitute accrued paid sick leave for unpaid FMLA leave.
If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of FMLA leave. Arrangements for payment have been discussed with you and it is agreed that you will make premium payments as follows:
- You have a minimum 30-day grace period in which to make premium payments. If payment is not made timely, your group health insurance may be canceled, provided you are notified in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share of the premiums during FMLA leave, and recover these payments from you upon your return to work. We will not pay your share of health insurance premiums while you are on leave.

You (will)(will not) be required to present a fitness-for-duty certificate prior to being restored to employment. If such certification is required but not received, your return to work may be delayed until the certification is provided.
You are not a "key employee" as described in § 825.218 of the FMLA regulations. If you are a "key employee," restoration to employment may be denied following FMLA leave on grounds that such restoration will cause substantial and grievous economic injury to us. We have not determined that restoring you to employment at the conclusion to FMLA leave will cause substantial and grievous economic harm to us.

The following information will be filled out after the Certification of Heath Care Provider form is received and reviewed:

While on leave, you (will)(will not) be required to furnish us with periodic reports every _____________________ of your status and intent to return to work. If the circumstances of your leave change and you are able to return to work earlier than the date indicated on the Response to Request for FMLA leave form, you will be required to notify us at least two (2) work days prior to the date you intend to report for work.
You (will)(will not) be required to furnish re-certification relating to a serious health condition upon request.

If you have any questions, please contact me at _____________________.

cc: Supervisor

Personnel File

Payroll (approved personnel only)