Uws 86 Form - University Of Wisconsin System Designation Notice printable pdf download

UNIVERSITY OF WISCONSIN SYSTEM

DESIGNATION NOTICE

(FAMILY AND MEDICAL LEAVE ACT)

It is the responsibility of the UW institution to designate leave as FMLA leave, whether under the federal FMLA, state FMLA, or both, and

to inform the employee of the amount of leave that will be counted against the employee’s FMLA leave entitlements. In order to

determine whether leave is covered under the FMLA, the UW institution may request that the leave be supported by a certification. If

the certification is incomplete or insufficient, the UW institution must state in writing what additional information is necessary to make

the certification complete and sufficient.

To: _________________________________________________________

Date: _________________________________

We reviewed your request for leave under the FMLA and any supporting documentation that you provided. We received your most

recent information on ______________________ and decided (see below):

Your FMLA leave request is approved and is effective on ______________. It is scheduled to end on ______________. All leave

taken for this reason will be designated as FMLA leave.

The FMLA requires that you notify us as soon as practicable if dates of scheduled leave change or are extended, or were initially

unknown. 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:

Per your FMLA leave request, the following number of hours, days, or weeks will be counted against your leave entitlement.

Please note that if you deviate from your anticipated leave schedule, these amounts may change. Leave entitlements under

FMLA, WFMLA, University Personnel Guidelines and employer guidelines run concurrently.

Federal FMLA: __________________________________

WI FMLA: _________________________________

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. You have the right to request this information from your employer once in a 30-day

period (if leave was taken in the 30-day period).

Comments:

Please be advised (check if applicable):

You requested to use paid leave during your FMLA leave. Any paid leave used will count against your FMLA leave entitlement.

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. A list of the essential functions of your position

is /

is not attached. If attached, the fitness-for-duty certification must address your ability to perform these functions.

Additional information is needed to determine if your FMLA leave request can be approved:

The certification you provided is not sufficient to determine whether FMLA applies to your leave request. You must provide the

following information by _______________ (seven calendar days from now), unless it is not practicable under the circumstances

despite your diligent good faith efforts, or your leave may be denied. The information still needed is:

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.

Your FMLA leave request is not approved.

Neither the federal nor the Wisconsin FMLA applies to your leave request.

You have exhausted your federal and/or Wisconsin FMLA leave entitlement(s) in the applicable 12-month period.

Signature of

Employer Agent:

_________________________________________________________

Date: _______________________

Note to UW Institutions. It is mandatory for employers to inform employees in writing whether leave requested under the FMLA has

been determined to be covered under the FMLA and for agencies to retain a copy of this disclosure in their records for three years.

UWS 86 (Rev 09/13)

Uws 86 Form - University Of Wisconsin System Designation Notice

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