Fillable Family Medical Leave Of Absence Request Form (Page 3 of 3) in pdf

YOUR RIGHTS AND RESPONSIBILITIES

under the

FAMILY MEDICAL LEAVE ACT (FMLA)

Leave can be taken intermittently or on a reduced leave schedule when medically

Basic Leave Entitlement

FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected

necessary. Employees must make reasonable efforts to schedule leave for planned medical

leave to eligible employees for the following reasons:

treatment so as not to unduly disrupt the employer’s operations. Leave due to qualifying

• For incapacity due to pregnancy, prenatal medical care or childbirth;

exigencies may also be taken on an intermittent basis

• To care for the employee’s child after birth, or placement for adoption or foster care;

• To care for the employee’s spouse, son or daughter, or parent, who has a serious

Substitution of Paid Leave for Unpaid Leave

health condition; or

Employees may choose or employers may require use of accrued paid leave while taking

• For a serious health condition that makes the employee unable to perform the

FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the

employee’s job.

employer’s normal paid leave policies.

Military Family Leave Entitlements

Employee Responsibilities

Employees must provide 30 days advance notice of the need to take FMLA leave when the

Eligible employees with a spouse, son, daughter, or parent on active duty or called to

active duty status in the National Guard or Reserves in support of a contingency

need is foreseeable. When 30 days notice is not possible, the employee must provide notice

operation may use their 12-week leave entitlement to address certain qualifying

as soon as practicable and generally must comply with an employer’s normal call-in

exigencies. Qualifying exigencies may include attending certain military events,

procedures.

arranging for alternative childcare, addressing certain financial and legal

arrangements, attending certain counseling sessions, and attending post-deployment

Employees must provide sufficient information for the employer to determine if the leave

reintegration briefings.

may qualify for FMLA protection and the anticipated timing and duration of the leave.

Sufficient information may include that the employee is unable to perform job functions, the

FMLA also includes a special leave entitlement that permits eligible employees to take

family member is unable to perform daily activities, the need for hospitalization or continuing

treatment by a health care provider, or circumstances supporting the need for military family

up to 26 weeks of leave to care for a covered servicemember during a single 12-

month period. A covered servicemember is a current member of the Armed Forces,

leave. Employees also must inform the employer if the requested leave is for a reason for

including a member of the National Guard or Reserves who has a serious injury or

which FMLA leave was previously taken or certified. Employees also may be required to

illness incurred in the line of duty on active duty that may render the servicemember

provide a certification and periodic recertification supporting the need for leave.

medically unfit to perform his or her duties for which the servicemember is undergoing

medical treatment, recuperation, or therapy; or is in outpatient status; or is on the

Employer Responsibilities

temporary disability retired list. In 2010 the definition of a Covered Service Member

Covered employers must inform employees requesting leave whether they are eligible

under FMLA. If they are, the notice must specify any additional information required as well

was expanded to include veterans who are undergoing medical treatment,

recuperation, or therapy for a serious injury or illness and who was a member of the

as the employees’ rights and responsibilities. If they are not eligible, the employer must

Armed Forces (including National Guard or Reserves) at any time during the five year

provide a reason for the ineligibility.

period preceding the date on which the veteran undergoes that medical treatment,

recuperation or therapy.

Covered employers must inform employees if leave will be designated as FMLA-protected

and the amount of leave counted against the employee’s leave entitlement. If the employer

Benefits and Protections

determines that the leave is not FMLA- protected, the employer must notify the employee.

During FMLA leave, the employer must maintain the employee’s health coverage

under any “group health plan” on the same terms as if the employee had continued to

Unlawful Acts by Employers

work. Upon return from FMLA leave, most employees must be restored to their

FMLA makes it unlawful for any employer to:

original or equivalent positions with equivalent pay, benefits, and other employment

• Interfere with, restrain, or deny the exercise of any right provided under FMLA;

terms.

• Discharge or discriminate against any person for opposing any practice made unlawful by

FMLA or for involvement in any proceeding under or relating to FMLA.

Use of FMLA leave cannot result in the loss of any employment benefit that accrued

prior to the start of an employee’s leave.

Enforcement

An employee may file a complaint with the U.S. Department of Labor or may bring a private

Eligibility Requirements

lawsuit against an employer.

Employees are eligible if they have worked for a covered employer for at least one

year, for 1,250 hours over the previous 12 months, and if at least 50 employees are

FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any

State or local law or collective bargaining agreement which provides greater family or

employed by the employer within 75 miles.

medical leave rights.

Definition of Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical or mental

FMLA section 109 (29 U.S.C. ß 2619) requires FMLA covered employers to post the

condition that involves either an overnight stay in a medical care facility, or continuing

text of this notice. Regulations 29 C.F.R. ß 825.300(a) may require additional

treatment by a health care provider for a condition that either prevents the employee

disclosures.

from performing the functions of the employee’s job, or prevents the qualified family

member from participating in school or other daily activities. Subject to certain

Any inquiries or complaints concerning the application of the Family and Medical Leave Act

conditions, the continuing treatment requirement may be met by a period of incapacity

and its implementing regulations as they relate to the University of Alabama at Birmingham

of more than 3 consecutive calendar days combined with at least two visits to a health

should be directed to the following office:

care provider or one visit and a regimen of continuing treatment, or incapacity due to

Human Resources Office

pregnancy, or incapacity due to a chronic condition. Other conditions may meet the

205/934-4408

definition of continuing treatment.

Use of Leave

The University of Alabama at Birmingham encourages individuals who have complaints to

An employee does not need to use this leave entitlement in one block.

contact Human Resources prior to contacting an outside agency. If you desire to utilize

UAB’s internal complaint procedure contact: Human Resources Relations.

Family Medical Leave Of Absence Request Form Page 3

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