University Of Maine System Request For Family Or Medical Leave Form Page 2

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You may be required to show evidence of birth or placement for adoption or foster care. Family and
Medical Leave may be used only in the first twelve months after birth or placement. After the twelve
month period any leave requested will be in accordance with policies for leave of absence without pay
for personal reasons.
employee’s serious medical condition or for care of a child, spouse,
If leave is requested for the
domestic partner, domestic partner’s child, sibling, or parent with a serious medical
condition,
certification from a health care provider is required and should be attached to this request. The
certification should be provided prior to the start of the leave or within 15 days of the leave request,
whichever is later. If proper certification is not provided, the leave request may be denied or delayed.
I understand that group health and dental coverage will continue on the same terms as during active
employment for any period covered by accrued paid leave. Group health and dental coverage will
continue on the terms of active employment for up to a total of 12 weeks of federal FMLA leave, or 10
weeks for state FMLA leave, including paid and unpaid leave. Group health and dental coverage will
continue on the terms of active employment for up to 26 weeks of FMLA leave for military caregiver
leave. Accrued paid leave must be used prior to leave without pay except that one week of annual leave
may be retained and an employee receiving Short Term Disability (STD) benefits may, but is not
required, use accrued leave to supplement STD payments. After exhausting paid leave, I understand
that any leave that extends beyond the FMLA limits (federal: 12 weeks; state: 10 weeks; military
caregiver: 26 weeks) will be considered leave for personal reasons and I will be responsible for the full
cost of group health and dental coverage. At the end of a Family and Medical Leave, I understand that
I may return to the job I held prior to the leave or an equivalent job. If the total leave exceeds 12 weeks
(or 26 weeks for military caregiver leave) and becomes a leave without pay for personal reasons, return
rights shall be in accordance with policies for leave without pay for personal reasons.
If leave is requested in the form of intermittent leave or reduced hours, it is my responsibility to
schedule leave so as to not unduly disrupt University operations, to the extent that is medically
feasible. If leave is in the form of intermittent leave or reduced hours, I understand that I may be
reassigned to an equivalent job for the period of the leave, if the position to which I am reassigned can
better accommodate the leave.
Employee Signature: ______________________________
Comments:
Immediate Supervisor Signature: ___________________________________
Department Head Signature: ______________________________________
Note to Supervisor and Department Head: Your signature acknowledges receiving the request form. Final
approval of the designation of the leave as FMLA is based on medical certification that is received in the Office
of Employee Health and Benefits. Please forward this form immediately to Human Resources, 124 Corbett
Hall. Please do not request or review any medical documentation. There is no special paid leave available
related to FMLA, but pay during an approved leave is based on using accrued leave appropriately.
OHR 2/13
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