Notice Of Eligibility And Rights & Responsibilities - Family And Medical Leave Act (Fmla) & California Family Rights Act (Cfra)
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NOTICE
ELIGIBILITY
RIGHTS & RESPONSIBILITIES
OF
AND
Family and Medical Leave Act (FMLA) & California Family Rights Act (CFRA)
In general, to be eligible for Family and Medical Leave (FML), an employee must have worked for the University for at
least 12 months and have worked at least 1,250 hours in the 12 months preceding the leave.
Part A – NOTICE OF ELIGIBILITY
To:
Employee
Date
From:
University Representative
On ____________________, you informed us that you needed leave beginning on ____________________and with an
anticipated end date of _____________________ for:
Parental leave following the birth of a child, or placement of a child with you for adoption or foster care.
Your own serious health condition, including pregnancy-related incapacity and prenatal care.
The need to care for your
spouse;
domestic partner;
child;
parent due to his/her serious health condition.
A qualifying exigency arising out of the fact that your
spouse;
domestic partner;
son or daughter;
parent who is a Covered Military Member on active duty or call to active duty status in support of a contingency
operation.
Military caregiver leave because you are the
spouse;
domestic partner;
son or daughter;
parent;
next of kin of a Covered Servicemember with a serious injury or illness.
This Notice is to inform you that:
You are eligible for FML and have FML entitlement remaining for the applicable 12-month period. (See Part B below
for Rights and Responsibilities.)
You are eligible for FML but your FML leave entitlement is exhausted for the applicable 12-month period.
You are not eligible for FML because:
You have not met the 12-month length of service requirement. As of the first date of requested leave, you
will have worked approximately _____ months towards this requirement.
You have not met the 1,250-hours-worked requirement.
If you have any questions, contact ________________________________________________________ or view the
FMLA and CFRA posters located in ___________________________________________ and online, as well as
applicable policies and/or collective bargaining agreement provisions.
Part B – RIGHTS AND RESPONSIBILITIES FOR TAKING FML (To be completed only if the employee is eligible and has
not exhausted his/her leave entitlement.)
As explained in Part A, you meet the eligibility requirements for taking FML and still have FML leave entitlement available
in the applicable 12-month period. However, in order for us to determine whether your absence qualifies as FML,
you should return the following information to us by ________________. When certification is requested,
employees have at least 15 calendar days from receipt of this notice to provide it. Under certain circumstances,
additional time may be provided. If sufficient information is not provided in a timely manner, your leave may be denied.
Sufficient certification to support your request for FML. A certification form that sets forth the information necessary
to support your request is enclosed.
Sufficient documentation to establish the required relationship between you and your family member. The required
declaration form is enclosed.
Other information needed: ______________________________________________________________________
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