Notice Of Eligibility And Rights & Responsibilities - Family And Medical Leave Act (Fmla) & California Family Rights Act (Cfra) Page 2
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1
2If your leave does qualify as FML, you will have the following responsibilities while on leave (only checked boxes
apply):
Contact ____________________ at ____________________to make arrangements to either (a) maintain your health
benefits during your leave by continuing to make your share of the premium payments or (b) opt out of your health
benefits during your leave. You have a minimum of 30 days to make premium payments. If payment is not made
timely, your group health insurance may be cancelled, provided we notify you 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 your FML,
and recover these payments from you upon your return to work.
You will be required to use your available paid
sick,
vacation, and/or
other leave during your FML absence.
This means that you will receive your paid leave and the leave will also be considered protected FML and counted
against your FML leave entitlement.
While on leave you will be required to furnish us with periodic reports of your status and intent to return to work every:
_________________________. [Indicate interval of periodic reports, as appropriate for the particular leave situation].
If the circumstances of your leave change, and you are able to return to work earlier than the date indicated in
Part A of this form, you need to notify your supervisor at least two workdays prior to the date you intend to
report for work.
If your leave does qualify as FML, you will have the following rights while on leave:
•
You have a right under the FMLA and/or the CFRA for up to 12 workweeks of unpaid leave in the calendar year
(January-December) if you are taking leave for any FML qualifying purpose other than Military Caregiver Leave.
•
You have a right under the FMLA for up to 26 workweeks of unpaid leave in a single 12-month period to care for a
Covered Servicemember with a serious injury or illness (Military Caregiver Leave). This single 12-month period
commenced or will commence on: _________________________.
•
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 and/or CFRA-protected leave. (If your leave extends beyond
the end of your FML leave entitlement(s), you do not have statutory return rights.)
•
If you do not return to work following FML for a reason other than: 1) the continuation, recurrence, or onset of a
serious health condition which would entitle you to FML; 2) the continuation, recurrence, or onset of a Covered
Servicemember’s serious injury or illness which would entitle you to FML; or 3) other circumstances beyond your
control, you may be required to reimburse the University for its share of health insurance premiums paid on your
behalf during your FML.
•
If we have not informed you above that you must use accrued paid leave while taking your unpaid FML leave
entitlement, you have the right to have
sick,
vacation, and/or
other leave run concurrently with your unpaid
leave entitlement, provided you meet any applicable requirements of the leave policy. Applicable conditions related to
the substitution of paid leave are referenced or set forth below. If you do not meet the requirements for taking paid
leave, you remain entitled to take unpaid FML leave.
For a copy of conditions applicable to sick/vacation/other leave usage please refer to _______________________
available at:__________________________________________________________________________________
Applicable conditions for use of paid leave:
_____________________________________________________________________________________
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 FML and count towards your FML leave entitlement. Meanwhile,
WE HAVE PROVISIONALLY DESIGNATED YOUR LEAVE AS FML. If you have any questions, please do not
hesitate to contact:
_________________________________________ at ____________________________
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NAME (PRINT)
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