Uthealth Request For Family And Medical Leave Form Page 2
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1
2Instructions:
All employees requesting Family and Medical Leave must complete the information on page one.
1.
If leave request is for medical reasons, the employee must provide a Certification of Health Care Provider form. The
2.
certification form must be submitted to the FML administrator within 15 calendar days following the initial leave
request.
Definitions:
Spouse - Is defined as a husband or wife in accordance with the law in the State of Texas. Unmarried domestic partners
do not qualify for family medical leave.
Parent - Includes biological parents and individuals who acted as your parents, but does not include parents-in-law.
Son/Daughter - Includes biological, adopted, foster children, stepchildren, legal wards, and other persons for whom you
act in the capacity of a parent and who is under 18 years of age, or over 18 years of age but incapable of caring for
themselves because of mental or physical disability.
Serious Health Conditions - Examples include heart attacks, heart conditions, most cancers and back conditions
requiring extensive therapy or surgical procedures, strokes, severe respiratory conditions, appendicitis, pneumonia,
emphysema, severe nervous disorders, injuries caused by serious accidents (on or off the job), pregnancy, severe
morning sickness, need for prenatal care, childbirth, recovery from childbirth and miscarriages.
Please Read Carefully:
I understand that my annual leave and sick leave balances (if applicable) will be applied towards my family medical
leave. I understand that I will be required to submit a completed Certification of Health Care Provider form if the reason
for my leave is for a serious health condition of my spouse, child, parent or myself.
If I take leave because of my own serious health conditions, I must provide the FML administrator with a Certification
of Fitness For Duty form from my physician or practitioner. I may be required to take a Fitness For Duty examination if
there is probable reason that I cannot perform the essential functions of my job. I understand that if the duration of leave
(or amount of time on the initial request) changes, it is my responsibility to contact my supervisor regarding the status
change and intent of my return to work.
I agree to continue to pay my share of the premiums for my health and welfare benefits and at the same time UTHealth
will continue to contribute its share of the premium cost for my medical coverage. If I fail to pay my premium by the
th
20
of the month, UTHealth reserves the right to cancel my optional coverage.
I understand I have the option to have my coverage held in abeyance prior to going on unpaid leave. Such coverage will
be suspended until I return to work. If the coverage is held in abeyance, I must submit a request to reinstate the same
coverage within 31 days upon returning from leave.
If I fail to return to work after a period of unpaid leave, and UTHealth has paid its share of the premium for maintaining
my medical insurance, UTHealth reserves the right to recover the premiums that were paid during my leave.
I understand that if my leave request is denied, I may protest the decision on an informal basis to my supervisor or
department head, or file a grievance in accordance with UTHealth’s Grievance Policy.
I understand there is no expectation for me to perform any work related tasks while I am on Family Medical Leave.
I understand that failure to return to work at the end of my leave period may be treated as resignation unless an
extension has been agreed upon and approved in writing by my supervisor.
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