Designation Notice (Family And Medical Leave Act) - The University Of Arizona

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DESIGNATION NOTICE
(Family and Medical Leave Act)
Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the employer must inform the employee of the amount of
leave that will be counted against the employee’s FMLA leave entitlement. In order to determine whether leave is covered under the FMLA, the employer may request
that the leave be supported by a certification. If the certification is incomplete or insufficient, the employer must state in writing what additional information is
necessary to make the certification complete and sufficient.
DATE:
_______________________
EMPL ID: __________________________________
TO:
_____________________________________________________________________
(Employee’s Name)
FROM: ____________________________________________________________________
DEPT #/NAME #: ______________________
(Supervisor Name/Designated Leave Coordinator)
On ____________________, you informed us that you needed FMLA leave beginning on __________________ with an anticipated end date of
(MM/DD/YY)
(MM/DD/YY)
_________________ (not to exceed FMLA leave entitlement) as a
continuous,
intermittent, and /or
reduced work schedule leave.
(MM/DD/YY)
We have reviewed your request for leave under the FMLA and any supporting documentation that you have provided. We received your most recent
information on ________________________________________ and decided:
(MM/DD/YY)
Your FMLA leave request is approved and 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:
Provided there is no deviation from your anticipated leave schedule, the following number of hours, days, or weeks will be counted
against your leave entitlement: ___________________________________________________________________ .
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 once in a 30-day period (if leave was taken in the 30-
day period).
Please be advised (check if applicable):
You are eligible for paid time benefits, as applicable (ie., sick time, vacation time, paid parental leave, and, for non-exempt employees,
compensatory time), any paid time used will be counted against the FMLA leave entitlement.
Your FMLA leave (or a portion of) will be unpaid because you are not eligible for accrued paid time or have you exhausted or will
exhaust your balance of accrued paid time.
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.)
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 have provided is not complete and sufficient to determine whether the FMLA applies to your leave request. You
must provide the following information no later than _________________________, unless it is not practicable under the particular
(Provide at least seven calendar days) - (MM/DD/YY)
circumstances despite your diligent good faith efforts, or your leave may be denied.
__________________________________________________________________________________________________________
(Specify information needed to make the certification complete and sufficient)
__________________________________________________________________________________________________________
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.
The University of Arizona – Division of Human Resources
FORM UAHR-FML-DESNOT-1014
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