FMLA ELIGILIBLITY (Check all that apply) Employee is eligible for FMLA (see Rights & Responsibilities below) Employee is not eligible for FMLA Employee has not worked FMLA entitlement has been exhausted at least 1,250 hours in the 12 months preceding the request ( OPS employees only ) _______________________________________ Immediate Supervisor 9s Signature _______________________________________________ Dean, Director, or Department Chairperson 9s Signature _______________________________________ Sr. Vice President 9s Signature (Academic Personnel Only) _______________________________________________ Employee 9s Signature I understand and accept a leave of absence as stated above. I also understand that this leave of absence will count toward my 12 weeks of FMLA entitlement if so designated above.<br><br> RIGHTS AND RESPONSIBILITIES FOR TAKING FMLA LEAVE As explained in the Notice of Eligibility, you meet the eligibility requirements for taking FMLA leave and still have FMLA leav e available in the applicable 12-month period. However, in order for us to determine whether your absence qualifies as FMLA leave, you must re turn the following information to us within 15 days of this notice. If sufficient information is not provided in a timely manner, y our leave may be denied.<br><br> ____ Certification of Health Care Provider for Employee 9s Serious Health Condition ____ Certification of Health Care Provider for Family Member 9s Serious Health Condition ____ Certification of Qualifying Exigency for Military Family Leave ____ Certification of Serious Injury or Illness of Covered Servicemember for Military Family Leave ____ No additional information requested You will have the following responsibilities while on FMLA leave: " You may elect to substitute accrued paid leave for unpaid FMLA leave in accordance with the usual requirements and procedures for using accrued paid leave. Also, if you normally pay a portion of the premiums for health benefits offered by th e University of Florida, these payments will continue during the period of FMLA leave. You have a minimum 30-day grace period in which to make premium payments.<br><br> If payment is not timely, your health benefits may be cancelled, provided the University Benefits Department notifies you in writing at least 15 days before the date that your coverage will lapse. If premium payments are not made via payroll deductions, you need to contact the University Benefits Department to make other arrangements. " You may be required to provide appropriate certification that you are able to return to work prior to being restored to employment.<br><br> If such certification is required but not received, your return to work may be delayed until the certification is provided. " If the need for FMLA leave is foreseeable, you must provide the University of Florida at least 30 days advance notice before th e leave is to begin. If 30 days notice is not practicable (for example, a medical emergency or change in circumstances) notice mu st be given as soon as practicable.<br><br> If you fail to provide the University of Florida proper notification as described above, the commencement of the leave may be delayed. " You are required to report periodically on your status and intent to return to work while on FMLA leave. If the circumstances of your leave change, and you are able to return to work earlier than the date indicated on the reverse si de of this form, you should contact your department to arrange an earlier return date.<br><br> You will have the following rights while on FMLA leave: " You have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated as a fixed year based on July 1 through June 30. " You have a right under the FMLA for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered servicemember with a serious injury or illness. This single 12-month period commenced on July 1.<br><br> " Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work. " You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not have return rights under FMLA.) " If you do not return to work following FMLA leave for a reason other than: 1) the continuation, recurrence, or onset of a serio us health condition which would entitle you to FMLA leave; 2) the continuation, recurrence, or onset of a covered servicemember 9s serious injury or illness which would entitle you to FMLA leave; or 3) 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.<br><br> Once we obtain the information from you as specified above, we will inform you, within 5 business days, whether your leave will be designated as FMLA leave and count towards your FMLA leave entitlement. DESIGNATION NOTICE Employee Name:____________________________________ Employee 9s UFID:____________________________________ Department:_______________________________________ Department Contact:_________________________________ Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform t he employee of the amount of leave that will be counted against the employee 9s FMLA leave entitlement. The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially unknown.<br><br> Your FMLA leave request is approved. All leave taken for this reason will be designated as FMLA leave. Based on the information you have provided to date, we are providing the following information about the amount of time that will be counted against your leave entitlement (check one): Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will be counted against your leave entitlement: ______________________________ Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or weeks that will be counted against your FMLA entitlement at this time.<br><br> You have the right to request this information once in a 30- day period (if leave was taken in the 30-day period). Please be advised (check if applicable): You have requested to use paid leave during your FMLA leave. Any paid leave taken for this reason will count against your FMLA leave entitlement.<br><br> You will be required to present a fitness-for-duty certificate to be restored to employment. If such certification is not timely received, your return to work may be delayed until certification is provided. Additional information is needed to determine if your FMLA leave request can be approved.<br><br> The certification you have provided is not complete and sufficient to determine whether the FMLA applies to your leave request. You must provide the following information no later than ______________________________, unless it is not practicable under the particular circumstances despite your diligent good faith efforts, or your leave may be denied. We are exercising our right to have you obtain a second or third opinion medical certification at our expense, and we will provide further details at a later time.<br><br> Your FMLA Leave request is Not Approved. The FMLA does not apply to your leave request. You have exhausted your FMLA leave entitlement in the applicable 12-month period.<br><br> _____________________________________ Immediate Supervisor 9s Signature _______________________________________ Employee 9s Signature

less