Designation Notice (Family And Medical Leave Act) - The University Of Arizona Page 2
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2(The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic
information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide
any genetic information when responding to a request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical
history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services,
and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.)
Your FMLA Leave request is Not Approved.
The FMLA does not apply to your leave request.
You have exhausted your FMLA leave entitlement in the applicable 12-month period.
DATE: ____________________________
(MM/DD/YY)
__________________________________________
__________________________________________
Supervisor/Designated Leave Coordinator
Contact #/Email
FORM ROUTING
Supervisor/Designated Leave Coordinator:
Original completed form to Employee
Maintain copy of form in confidential department file
Copy to Human Resources
ADAPTED FROM DEPARTMENT OF LABOR FORM WH-382, DOL REVISED JANUARY 2009, OMB CONTROL NUMBER 1235-0003
The University of Arizona – Division of Human Resources
FORM UAHR-FML-DESNOT-1014
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